NHTSA State EMS
Assessments
Since 1988, the National Highway Traffic Safety Administration has conducted Technical Assistance Team assessments of state EMS systems at the request of individual states. These reports evaluate ten core components of EMS infrastructure — from regulation and workforce to trauma systems and evaluation (with preparedness added after 2001) — providing the most detailed federal examination of state-level EMS available. Because no central public repository exists, this archive represents reports obtained through public records searches, state websites, internet archives, libraries, and state public records requests.
The NHTSA Technical Assistance Team Process
The NHTSA Technical Assistance Team (TAT) assessment program began in 1988 as a voluntary, state-requested evaluation of EMS system development. A team of national subject matter experts conducts a multi-day site visit, interviews dozens of stakeholders, and produces a comprehensive report evaluating the state’s EMS system against eleven standard components.
The eleven components assessed include: regulation and policy, resource management, human resources and education, transportation, facilities, communications, trauma systems, public information and education, medical direction, evaluation, and (in later assessments) preparedness.
Initial assessments establish a baseline. Reassessments, requested years or decades later, measure progress against prior recommendations. The intervals between assessments have grown over the life of the program — from 8–13 years in the 1990s to gaps of 27 years (Georgia) and 33 years (Kentucky) in recent assessments.
This collection contains 29 accessible reports spanning 26 unique states, with four states assessed twice within the corpus. All reports were obtained through public records searches, state websites, internet archives, libraries, and state public records requests — not from NHTSA directly. Additional assessments may have been conducted but are not publicly available or could not be located. Each report is paired with a structured analysis extracting key findings across standardized dimensions. The original PDFs are available for download alongside each analysis.
Alaska
Full Analysis
Alaska 1999 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of Alaska
- Report type: Reassessment
- Date of site visit: September 7–9, 1999
- Year of publication: 1999
- Prior assessment year: 1992
- TAT members:
- Bob W. Bailey
- Gail Cooper
- W. Daniel Manz
- Susan McHenry
- Stuart A. Reynolds, MD, FACS
- John C. Sacra, MD, FACEP
- NHTSA facilitator: Susan McHenry (dual role — listed as both TAT member and NHTSA facilitator role)
- Number of presenters/briefings: Over 25 presenters
"over twenty five presenters from the State of Alaska, provided in-depth briefings on EMS and trauma care"
- Requesting agency: Alaska Emergency Medical Services Office in concert with the Alaska Highway Safety Office
SECTION 2: STATE CONTEXT
- Population (as cited in report): Described as "one of America's smallest resident populations" but no specific figure cited.
- Geographic characteristics: The report provides extensive geographic characterization:
"Land area far larger than any other state in the nation is home to one of America's smallest resident populations."
"The State's wide expanses, diverse geography and scant population in many remote regions combined with brutally severe weather conditions create problems uniquely Alaskan."
Transportation challenges include distances, alternative transport modes (snow machines, dog sleds, trucks), satellite phone as the only communication in some villages, and the need to transport patients to Seattle (Harborview Level I) from the southeast region. Microwave wireless radio links along major highways are incomplete. Some villages have "only satellite phone and some even more limited communications."
- Number of counties/jurisdictions: Not described as counties. Alaska uses a borough/census area system. The report references "Regions" and "sub-regional groups" without specifying county-equivalents.
- EMS system overview:
- Lead agency: Alaska Department of Health and Social Services, Division of Public Health, Section of Community Health and Emergency Medical Services, EMS Unit (located in Juneau)
- Advised by the Governor-appointed Alaska Council on Emergency Medical Services (ACEMS) — 11 members
- Two contract physicians serve as State EMS Co-Medical Directors (function "primarily as technical advisors")
- Regional EMS Councils and sub-regional groups handle program implementation
- EMS Unit provides substantial annual contract funding to regional/sub-regional groups
- Alaska State Medical Board licenses Paramedics; EMS Unit certifies all other EMT levels
- Commission on Post-secondary Education has regulatory authority over most post-secondary offerings — potential conflict with EMS Unit oversight of training
- Ground services: 5 BLS, 45 BLS/ALS, 37 ALS
- Air medical: 10 Medevac, 10 Critical Care, 1 Specialty Air Service
- 125 ground ambulances (41 over 15 years old)
- 24 hospitals (15 civilian, 6 Alaska Native, 1 Native Consortium, 2 Military)
- 35 trained Emergency Medical Dispatchers
- Community Health Aides (CHAs) serve as supplementary EMS providers in rural areas
- Emergency Trauma Technician (ETT) certification for first responders
- EMS training levels: ETT, EMT-I (Basic), EMT-II (Intermediate), EMT-III (Cardiac Technician), EMT-Paramedic
- Notable demographic or socioeconomic factors cited:
"A variety of other issues influence response time, scene time, transport time, and procedures including distances between providers and those served, the volunteer nature of much of the EMS service in the state, variation in training as well as language and cultural diversity."
The report references Native Alaskans, Alaska Native health corporations, Indian Health Service (IHS) compacting, and cultural diversity as significant system factors. The decline of IHS funding through "compacting" is identified as a major financial threat.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:
"An 'Alaska EMS Goals' document identifies expected standards for the state EMS system and provides a foundation for linking work expectations with the funding of regional contracts."
"Integrate existing planning documents into a single comprehensive statewide EMS plan with implementation priorities."
(b) Specific data points:
- Planning documents in place: "Alaska EMS Goals," Strategic Plan for EMS, 5-year EMSC Strategic Plan, Injury Prevention Plan, Childhood Injury Prevention Plan, "Code Blue" report on rural EMS
- No single comprehensive statewide EMS plan exists
- Regional and sub-regional structure in place for implementation
- Trauma triage/transfer guidelines adopted but not translated into local/regional protocols
(c) Report characterization: Multiple planning documents exist but are not integrated into a single comprehensive plan. The TAT recommends consolidation.
(d) Priority recommendation status: Yes. Integration into a single plan with implementation priorities is recommended.
3B. Funding and Financial Sustainability
(a) Direct quotes:
"The daunting task of developing a comprehensive statewide EMS system is made even more difficult at a time of diminishing resources."
"There is wide variation in funding ranging from the generously supported North Slope Borough Fire Department to the opposite end of the spectrum in Yukon Kuskokwim EMS."
"The limited availability of state funds, inconsistency in local revenue sources and the recent changes in Indian Health Services fund distribution combine to create significant challenges for the future."
"Some of the traditional funding sources for EMS system development have been examined and found to be unfeasible while other non-traditional sources have been determined unconstitutional."
"This unfunded mandate has increased communications costs to the EMS Unit from $146,000 in 1994 to $236,000 in 1999."
(b) Specific data points:
- EMS Unit communications costs: increased from $146,000 (1994) to $236,000 (1999) due to charge-back system
- $65,000 budget shortage facing EMS Unit due to communications charge-backs
- $500,000 identified to begin implementing State EMS communications plan (insufficient for full implementation)
- State capital equipment program for ambulances: discontinued
- 41 of 125 ambulances over 15 years old
- IHS "compacting" threatens reallocation of EMS funds to other health priorities
- Some funding sources explored and found "unfeasible"; others "unconstitutional"
- Suggested funding exploration: Medicaid administrative claiming, Welfare to work, Tobacco settlement funds
(c) Report characterization: The TAT characterizes funding as at a crisis point — "diminishing resources" combined with new unfunded mandates, discontinued capital programs, and the existential threat of IHS compacting. The variation from North Slope Borough to Yukon Kuskokwim highlights extreme geographic funding disparities.
(d) Priority recommendation status: Yes. Multiple funding recommendations including relief from charge-backs, investigation of new revenue sources, and a Governor's task force on IHS compacting effects.
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:
"Solitary Emergency Trauma Technicians, with little on-line medical support, respond to travelers, friends, family and neighbors. Not only does this volunteer effort take time from families and primary occupations but it also takes a heavy emotional toll in treating close friends and family members."
"Recruitment and retention of these critical volunteers is vital to the survival of the system in its current form."
"Human resources are variable across the State. Rural, isolated volunteer providers have significant issues with recruitment and retention, while in the more urban areas these issues are somewhat more stable."
"It is not known how many of these previously trained personnel continue to practice their skills within the organized system of response."
(b) Specific data points:
- "Several thousand EMS trained personnel" in the state (exact count not provided)
- EMS training levels: ETT, EMT-I, EMT-II, EMT-III, EMT-Paramedic
- Community Health Aides (CHAs) supplementing EMS — being trained to ETT and EMT-I levels
- State EMS Training Coordinator position lost during government reorganization
- EMSC Coordinator: part-time (40%), increasing to 80%
- Minimum transporting staffing: at least one EMT-I
- Inactive EMS personnel population: number and reasons unknown
- No exit interview process for departing EMTs
(c) Report characterization: The TAT describes rural volunteer EMS in deeply personal terms — "solitary" providers treating "close friends and family members" at a "heavy emotional toll." Recruitment and retention are characterized as "vital to the survival of the system in its current form." The loss of the state training coordinator is noted by multiple presenters.
(d) Priority recommendation status: Yes. Surveys of inactive personnel, exit interviews, retention analysis, mentor programs, and a "Locum Tenens" program for ALS personnel in rural areas are recommended.
3D. Essential Service Designation
(a) Direct quotes: Not documented in this report.
(b) Specific data points: The report does not discuss essential service designation.
(c) Report characterization: The concept of EMS as an essential service is not addressed.
(d) Priority recommendation status: Not documented in this report.
3E. Regulatory Fragmentation
(a) Direct quotes:
"An historical aberration of the regulatory process requires the Department of Health and Social Services to obtain the approval of the Department of Public Safety before changing any EMS rules"
"The Alaska State Medical Board has the responsibility for licensing Paramedics while the EMS Unit handles certification of all other levels of EMTs"
"A Commission on Post-secondary Education within the Department of Education has broad regulatory authority over most post-secondary offerings. That may represent a conflict with the EMS Unit's oversight of EMS training programs."
(b) Specific data points:
- EMS rules require Department of Public Safety approval — "historical aberration"
- Paramedic licensure: Alaska State Medical Board
- All other EMT certification: EMS Unit
- EMS training oversight: potential conflict between EMS Unit and Commission on Post-secondary Education
- 14 ground services not licensed
- Ambulance inspection: not in place; licensing is "self assessment and reporting"
- No standards for dispatch centers
- No common mutual aid radio frequency
- Some rural areas have no radios; others only CB radios
(c) Report characterization: The TAT identifies a three-way regulatory fragmentation: EMS Unit, Medical Board (paramedics), and Commission on Post-secondary Education (training). The Public Safety Department approval requirement is called an "historical aberration."
(d) Priority recommendation status: Yes. Elimination of Public Safety approval requirement, clarification of education authority, and transfer of training authority to EMS Unit are recommended.
3F. Data and Evaluation Systems
(a) Direct quotes:
"Currently a comprehensive evaluation program does not exist."
"Data collection does not occur for EMS patients other than trauma because a mandatory uniform EMS run form or the NHTSA minimum data set has not yet been implemented."
"A standardized run form has been created and electronic data entry is planned. However, system-wide collection of data and appropriate feedback to individual Medical Directors are lacking."
"the voluntary Trauma Registry is an example of a major success in data collection and evaluation. Although only the one certified Trauma Center is required to submit data, all hospitals voluntarily participate."
(b) Specific data points:
- Trauma Registry: voluntary participation by all Alaska hospitals — "major success"
- Only 1 certified Trauma Center required to submit data
- Smaller hospitals given grants to assist data collection
- Trauma registry linked to crash reports, FARS, medical examiner reports, hospital discharge data
- No mandatory EMS run form or minimum data set implemented
- Standardized run form created but not implemented system-wide
- Annual EMS Survey: 85% return rate
- No statewide EMS data collection for non-trauma patients
- No comprehensive CQI program
- No medically directed outcome parameters established
- Confidentiality protection by statute for Trauma Registry; status of other EMS data protection pending Attorney General ruling
(c) Report characterization: The TAT characterizes evaluation as having two extremes: the Trauma Registry is a "major success" with 100% voluntary hospital participation, while non-trauma EMS data collection essentially does not exist. The TAT commends the trauma registry as a model but identifies the absence of comprehensive EMS data as a critical gap.
(d) Priority recommendation status: Yes. Implementation of uniform EMS run form/minimum data set is recommended, along with NHTSA EMS Information System Workshop and CQI program development.
3G. Trauma System Status
(a) Direct quotes:
"There has been remarkable activity in the development of enhanced trauma care since the last visit of the TAT"
"the statutory authority does not include development of a State Trauma Care Plan or the authority for Trauma System Development"
"there continues to be little evidence of recognition of the importance of commitment to system development on the part of most general surgeons in Anchorage"
"Severely injured patients are not being triaged to the verified center"
(b) Specific data points:
- Statutory authority exists for trauma center "certification" (Levels I–IV based on ACS/COT criteria) and trauma registry maintenance
- No statutory authority for State Trauma Care Plan or Trauma System Development
- 1 ACS/COT Level II verified trauma center: Alaska Native Medical Center (application for State Level II certification pending)
- Providence Medical Center: pursuing ACS verification
- Level I–III certification based on ACS verification; Level IV based on in-state team visit
- Trauma triage/transfer guidelines created but extent of utilization "unclear"
- Southeast region patients appropriately triaged to Harborview (Seattle) — Level I
- HCFA conflicts over out-of-state referral patterns
- Trauma registry: all hospitals participate voluntarily
- No prehospital injury severity criteria in Anchorage urban area
- Rehabilitation resources guideline available but reimbursement problems exist
(c) Report characterization: The TAT uses "remarkable" to describe progress since 1992 but identifies critical gaps: no authority for system development, lack of surgeon commitment in Anchorage, and failure to triage severely injured patients to the verified center. The dependence on Harborview in Seattle for Level I trauma care is documented as the appropriate pattern for the southeast region.
(d) Priority recommendation status: Yes. Statutory authority for comprehensive trauma system plan, prehospital injury severity criteria, triage to highest-level center, and trauma registry CQI are recommended.
3H. Medical Direction
(a) Direct quotes:
"Currently in Alaska the medical care system involving the oversight of medical practice as delegated by physicians to non-physicians is required only for Advanced Life Support."
"The current system requires no oversight for BLS and oversight for ALS is inconsistent from service to service."
"The role of the State Medical Director for EMS is defined legislatively but the position is not well defined as to its responsibilities or authority."
"There are two state co-Medical Directors who function primarily as technical advisors to the EMS Unit."
"On-line medical direction is the exception rather than the rule for all of Alaska"
"Treatment protocols (off-line) for both adults and pediatric patients have been developed, however, they are not yet in use."
"The current physician medical directors are to be commended for their dedicated and largely volunteer efforts."
(b) Specific data points:
- 2 State EMS Co-Medical Directors (contract, function as technical advisors)
- Medical direction not required for BLS
- ALS oversight "inconsistent from service to service"
- On-line medical direction: "the exception rather than the rule"
- Treatment protocols developed but not yet in use
- No standardized CQI approach
- Medical Director Manual updated 1996 — described as confusing with roles not clearly articulated
- No formal procedure for expanding scope of practice
- No standardized approach for monitoring training or on-line medical control
- No mechanism for regular communication between medical directors (beyond annual symposium)
(c) Report characterization: The TAT identifies significant gaps: BLS operates without medical oversight, ALS oversight is inconsistent, protocols are developed but not implemented, and online medical direction is rare. The Co-Medical Directors are praised for "dedicated and largely volunteer efforts" but their role as "technical advisors" lacks defined authority.
(d) Priority recommendation status: Yes. Extensive recommendations on defining roles/authority at all levels, implementing protocols, analyzing BLS medical direction requirement, exploring paid medical direction, and establishing CQI standards.
3I. Communications and Infrastructure
(a) Direct quotes:
"the TAT is concerned that a communications crisis is currently facing EMS and other public safety users of the state communications system. Given our belief that the communications infrastructure is in danger of collapse the TAT believes that only two recommendations are warranted."
"any additional recommendations regarding EMS communications and dispatch are inconsequential unless the following two recommendations are implemented"
"some villages have only satellite phone and some even more limited communications"
"There is no common mutual aid frequency and some rural areas have no radios at all. Other areas only have access to CB radios."
(b) Specific data points:
- Over 90% of population covered by 9-1-1
- 120 microwave wireless radio links along major highways (system incomplete)
- 12 highway call boxes (EMS Unit pays for 4; would need 347 more to complete)
- 50 Iridium satellite phones purchased for rural "black holes"
- 35 trained EMDs statewide
- Communications costs: $146,000 (1994) → $236,000 (1999)
- $65,000 budget shortage due to charge-backs
- $500,000 identified for communications plan implementation (insufficient)
- No dispatch center standards
- No common mutual aid frequency
- Some areas: no radios or CB radios only
- Some villages: satellite phone only or "even more limited"
- State EMS Communications Plan developed
(c) Report characterization: The TAT uses "crisis" and "danger of collapse" — the strongest language on communications infrastructure in the entire corpus to date. The TAT makes the unusual decision to limit recommendations to just two, stating all other communications needs are "inconsequential" unless the infrastructure is preserved. This is the only section where the TAT explicitly subordinates all other recommendations to a single survival issue.
(d) Priority recommendation status: Yes — characterized as existentially urgent. Only two recommendations made: joint legislative approach for comprehensive communications funding and relief from charge-back unfunded mandate.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (1992 Assessment)
This report includes a formal "Progress on Meeting 1992 Recommendations" section within each topic area — a significant structural difference from the Georgia, Iowa, and Idaho reports, and similar to the Kentucky report format. The 7-year gap between assessment (1992) and reassessment (1999) is the shortest in the corpus.
Documented Progress:
Regulation and Policy:
- ✅ Updated EMS legislation and new rules
- ✅ EMS Goals document developed
- ✅ Regional communications improved to "cooperative collaboration"
- ❌ Traditional funding sources found "unfeasible"; non-traditional sources "unconstitutional"
Resource Management:
- ✅ EMS Goals and strategic plan developed
- ✅ Information sharing improved among regions
- ✅ Continuing EMT-I in every village/community goal
- ✅ More CHAs trained to ETT/EMT-I
Human Resources:
- ✅ National EMT-Basic curriculum adopted
- ✅ EMT-P training reestablished through private academy
- ✅ Regional EMT training expanded
- ✅ CHA curriculum integrated with EMS training
- ✅ Bloodborne pathogen protocol completed
Transportation:
- ✅ Trauma triage/transport/transfer guidelines adopted
- ❌ Not translated into specific local/regional protocols
Facilities:
- ✅ Community categorization (Villages, Sub-regional, Regional, Urban Centers)
- ✅ ACS criteria adopted for trauma certification
- ✅ Trauma triage/transfer guidelines adopted
- ❌ Facilities not categorically described by capability
Communications:
- ✅ E911 pursuit supported
- ✅ Communications survey completed
- ✅ State EMS Communications Plan developed
- ✅ New technology reviewed (satellite systems)
- ✅ EMD training initiated
PI&E:
- ✅ Strong progress on all original recommendations
- ✅ Injury Prevention Plan and Childhood Injury Prevention Plan written
- ✅ Trauma registry used for public awareness
- ✅ EMSC program targeting schools/children
Medical Direction:
- ✅ Medical Director Manual updated (1996)
- ⚠️ Format "confusing," roles "not clearly articulated"
- ✅ Treatment guidelines for specialized areas developed
- ❌ Comprehensive BLS/ALS protocols not implemented statewide
- ⚠️ Job descriptions progressed but authority/relationships not defined
- ✅ Standardized run form created
- ❌ System-wide data collection/feedback not implemented
- ✅ Liability protection ensured
- ✅ Minimum scope of practice adopted
- ❌ No formal scope expansion procedure
Trauma Systems:
- ✅ DOTS workshop completed (1994)
- ✅ ACS/COT consultation visits to potential Level II hospitals
- ✅ Statutory authority for trauma certification and registry
- ✅ Trauma registry: all hospitals participating voluntarily
- ✅ Trauma triage/management guidelines created
- ✅ Rehabilitation resources guideline available
Evaluation:
- ⚠️ Plan for standardized run form/minimum data set — not yet implemented
- ✅ Trauma Registry feedback to hospitals — "significant accomplishment"
- ❌ Pre-hospital performance measurement not yet possible
- ✅ Trauma data used for education and prevention
- ✅ Section 402 dollars successfully pursued
- ✅ Statutory protection for trauma registry data
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall System Characterization
"Alaska is a world of striking contrasts."
"the spirit of Alaska is embodied in its EMS system. All members of the community work together from military pre-hospital resources, to full-time dedicated EMS professionals, to Native Alaskan's, to volunteers who care for their villages as well as travelers without regard to extrinsic rewards."
"Alaskans can be justifiably proud of the system now in place."
"There is much to do while the sun shines as 'termination dust' is falling on the mountain tops."
The introduction is the most evocative in the corpus, using Alaskan imagery (termination dust, long summer days, perpetual winter darkness) to frame both the achievement and urgency. The phrase "termination dust" — early snowfall on mountaintops signaling winter's approach — serves as metaphor for approaching challenges.
Structural Barriers Identified
1. Communications infrastructure "in danger of collapse" — the only section where all other recommendations are subordinated to survival
2. IHS compacting — threatening reallocation of EMS funds to other health priorities
3. Diminishing state resources — capital equipment program discontinued, charge-back unfunded mandate
4. Geographic extremes — vast distances, severe weather, remote/inaccessible villages, alternative transport modes
5. Regulatory fragmentation — EMS Unit, Medical Board, Post-secondary Education Commission, Public Safety Department approval requirement
6. Volunteer recruitment/retention — "vital to the survival of the system"
7. No comprehensive EMS data collection for non-trauma patients
8. Medical direction gaps — BLS unmonitored, ALS inconsistent, protocols not implemented
9. No trauma system development authority — only certification authority exists
10. Cultural and linguistic diversity — identified as influencing EMS delivery
Transportation vs. Healthcare Framework
The 1999 report references the 1996 EMS Agenda for the Future as its conceptual framework — a significant marker as this document represented the transition from a transportation to a healthcare paradigm. The report operates firmly within both:
"NHTSA has determined that it can best use its limited resources if its efforts are focused on assisting States with the development of integrated emergency medical services (EMS) programs that include comprehensive systems of trauma care."
The Alaska Highway Safety Office co-requested the assessment, and Section 402 highway safety funds are referenced. But the system description emphasizes the healthcare dimension: Native health corporations, Community Health Aides, IHS integration, hospital capabilities.
Federal Funding Mechanisms Referenced
- NHTSA Highway Safety funds (Section 402)
- EMSC grant
- IHS funding (threatened by compacting)
- Medicare Rural Hospital Flexibility Program (MRHFP) grant
- Smaller hospital grants for trauma data collection
Greatest Strengths (as identified by the TAT)
- Trauma Registry — 100% voluntary hospital participation, "major success"
- PI&E program — "vigorous and visible," "commendable," "should serve as a model"
- Community Health Aide integration
- Alaska Highway Safety Office partnership
- Kids Don't Float and Safe Communities programs
- Rehabilitation resources guideline
- Regional coordination structure
- EMSC program
- Spirit of community collaboration across military, Native, volunteer, and career providers
- Distance learning (Behavioral Emergencies program described as "exceptional")
Most Critical Challenges (as identified by the TAT)
- Communications infrastructure "in danger of collapse"
- IHS compacting threat to EMS funding
- 41 of 125 ambulances over 15 years old
- No comprehensive EMS data system
- Medical direction not required for BLS; inconsistent for ALS
- Treatment protocols developed but not implemented
- No trauma system development authority
- Severely injured patients not triaged to verified center (Anchorage)
- General surgeon disengagement from trauma system development
- State EMS training coordinator position lost
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
"Communications Crisis" — Strongest Language in Corpus
"a communications crisis is currently facing EMS... the communications infrastructure is in danger of collapse"
"any additional recommendations regarding EMS communications and dispatch are inconsequential unless the following two recommendations are implemented"
No other report in the corpus subordinates all recommendations within a section to a single existential priority. The TAT's decision to issue only two communications recommendations — down from what would typically be many — signals the severity.
IHS Compacting as Unique Threat
The "compacting" of Indian Health Service funds — allowing tribal entities to administer federal health funds directly — is identified as a threat to EMS funding. This is a funding mechanism unique to states with significant Native populations and does not appear in the other reports analyzed.
Community Health Aides as EMS Extension
The use of Community Health Aides (CHAs) — a workforce unique to Alaska's IHS system — as EMS providers at the ETT and EMT-I level is a staffing model not documented elsewhere in the corpus. The TAT recommends extending CHA utilization to villages outside the IHS system.
Alternative Transport Modes
"the creative use of alternative modes of transportation to overcome the many geographic complications... (e.g. snow machines, dog sleds, trucks)"
This is the only report in the corpus referencing non-traditional EMS transport modes.
"Termination Dust" Metaphor
The closing line — "There is much to do while the sun shines as 'termination dust' is falling on the mountain tops" — is the most literary and urgently metaphorical language in the corpus, using a specifically Alaskan image to signal approaching difficulty.
Out-of-State Trauma Dependence
Like Idaho, Alaska depends on out-of-state Level I trauma care (Harborview in Seattle). Unlike Idaho, this dependence generates federal HCFA conflicts over reimbursement for cross-state referral patterns.
Solitary Providers
"Solitary Emergency Trauma Technicians, with little on-line medical support, respond to travelers, friends, family and neighbors."
The image of a single ETT treating family members and neighbors in an isolated village with minimal communications is the most granular depiction of rural EMS found in the corpus.
Self-Assessment Licensing
Ground ambulance licensing is described as "self assessment and reporting" — with 14 services not licensed and no inspection program in place. This represents the least formalized licensing structure in the corpus.
1999 Report as Temporal Marker
As a 1999 report, this is the earliest in the corpus and predates NEMSIS, the National EMS Scope of Practice Model (2007), the EMS Compact, and many other national standardization efforts referenced in later reports. The absence of these frameworks is itself a data point — the recommendations focus on foundational elements (standardized run forms, basic data collection, implementing already-developed protocols) that later reports treat as established infrastructure.
Shortest Reassessment Gap
The 7-year gap between the 1992 assessment and 1999 reassessment is the shortest in the corpus (compared to Kentucky 33, Idaho 31, Georgia 27, Iowa unknown). This may correlate with the inclusion of formal "Progress on Prior Recommendations" sections — closer temporal proximity may facilitate accountability tracking.
Report Structure: Formal Progress Tracking
Unlike Georgia (2022), Iowa (2015), and Idaho (2024), the Alaska 1999 report includes formal "Progress on Meeting 1992 Recommendations" sections in every topic area. This provides systematic accountability tracking and is shared only with the Kentucky 2024 report in the current corpus.
Analysis completed per standardized NHTSA State EMS Assessment framework. No synthesis or editorial interpretation has been applied. Findings are extracted as documented in the report.
Full Analysis
Alaska 2014 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Alaska
- Report type: Reassessment
- Date of site visit: May 13–15, 2014
- Year of publication: 2014
- Prior assessment year: 1999 (Background, p.5: "reviewed the progress since the 1999 Reassessment")
- TAT members:
- D. Randy Kuykendall, MLS
- Dan Manz
- Curtis Sandy, MD, EMT-T, FACEP
- Jolene R. Whitney, MPA
- NHTSA facilitator: Susan McHenry, MS
- Administrative consultant: Janice D. Simmons, BFA
- Number of presenters/briefings: Over 20 presenters over the first day and a half (Background, p.5)
- Requesting agency: Alaska Department of Health and Social Services, Emergency Medical Services Unit
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not stated numerically. Described as having "sparse population" (Trauma Systems, p.35). 55% of population within 1 hour of a Level I or II trauma center (Trauma Systems, p.35). Only 70% of population has access to 911 or E911 (Communications, p.28).
- Geographic characteristics: Largest state by area; vast frontier; glaciers, icebergs, open plains, expansive mountains; communities "often widely dispersed and not connected by land-based roads" (Introduction, p.8); "few roads" (Transportation, p.22); extreme weather conditions; "the geography, vast distances, sparse population and climate challenge equally the care of individual patients and EMS system development" (Trauma Systems, p.35)
- Number of counties/jurisdictions: 7 EMS regions (structured as 501(c)(3) nonprofits); boroughs mentioned but not enumerated
- EMS system overview:
- Section also includes Trauma Services Program (TSP) and Health Emergency Response Operations (HERO)
- EMS Unit: 7 authorized state positions (2 vacant at time of visit); based in Juneau
- TSP and HERO based in Anchorage (geographic separation from EMS Unit)
- State EMS Medical Director: contracted emergency physician
- 7 EMS regions (501(c)(3) nonprofits) — each with Executive Director, Medical Director, and staff
- Alaska Council on EMS (ACEMS): 11 Governor-appointed members
- 101 certified ambulance services (BLS, BLS/ALS, ALS)
- 17 certified air medical services; 9 with pending certification
- Over 350 vehicles statewide
- EMS workforce: 2,122 EMT1s, 582 EMT2s, 778 EMT3s, 381 MICPs, 165 instructors, 65 medical directors, over 800 ETTs
- 24 licensed acute care hospitals
- 3 academic-based paramedic programs (CAAHEP accredited)
- Alaska State Medical Board licenses paramedics; EMS Unit certifies all other EMT levels
- Notable demographic or socioeconomic factors cited: Highest rate of occupational fatalities in the U.S.; third highest mortality due to injury (Trauma Systems, p.35). Native Alaskan culture integrated into EMS system design. Community Health Aide Program (CHAP) provides primary and emergency care in remote villages. Inupiat values cited in Introduction.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:An EMS Goals document that served as the state EMS plan has not been updated in many years and is no longer an effective tool in guiding system development priorities." (Regulation and Policy, p.11)
Alaska has made little if any progress on updating its EMS statutes, regulations and plans since the 1999 EMS Reassessment." (Regulation and Policy, p.11)(b) Data points: EMS Goals document exists but has not been updated in many years. Regulations last updated 2002; later update efforts "fell by the wayside after being derailed by procedural missteps during the implementation process." No comprehensive integrated strategic plan exists. (c) TAT characterization: Outdated plan described as "no longer an effective tool." "Little if any progress" since 1999. (d) Priority recommendation: Develop an integrated statewide strategic plan addressing EMS, trauma, and health preparedness. Perform comprehensive update of EMS statutes, regulations, and plans.
3B. Funding and Financial Sustainability
(a) Direct quotes:The support available is woefully inadequate to support the long-term stability of the many remote EMS systems and agencies that serve the geographic majority of the state." (Resource Management, p.15)
Continued reliance on annual general fund allocations fails to ensure long-term stability for future system needs and expansion as well as limiting planning opportunities." (Resource Management, p.15)(b) Data points:
- Funding from general funds allocated annually by Legislature
- Code Blue program: established 14 years prior; $500,000 general fund contribution in 2014 (increased 20%)
- Code Blue provides high-cost equipment and education to local EMS systems
- Outside grant funding for Code Blue has decreased
- Regional funding through annual contracts; some decline in regional support funding
- 2014 budget includes 20% incremental increase in regional support
- 2 of 7 authorized EMS Unit positions vacant
- FY 2015: Department adjusting accounting to place Code Blue funds within Section's budget
- No dedicated funding source; annual general fund allocations only
- Code Blue described as "ideal vehicle" for developing dedicated grant funding system
- Legislature should work with stakeholders to identify a dedicated funding source sufficient to meet EMS system needs
- Section should fill all existing vacancies and evaluate need for additional personnel
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:There was a wide perception among presenters that volunteerism is declining and maintaining a sufficient workforce has become a significant challenge facing the Alaska EMS system." (Human Resources, p.18)
The testing of EMS personnel at the end of education courses and prior to beginning practice is currently done using a written examination developed by the Unit that is acknowledged to be partially compromised and of questionable validity." (Human Resources, p.19)(b) Data points:
- 2,122 EMT1s, 582 EMT2s, 778 EMT3s, 381 MICPs (paramedics)
- 165 certified instructors
- 65 medical directors
- Over 800 ETTs (Emergency Trauma Technicians — first responder level)
- 3 CAAHEP-accredited paramedic programs
- Curricula based on increasingly outdated National Standard Curricula (not yet aligned with National EMS Education Standards)
- Testing every 2 years for continued authorization — burden considered a factor in turnover
- State-developed written exam "partially compromised and of questionable validity"
- NREMT testing not adopted; reluctance among some stakeholders
- Paramedic licensing by State Medical Board causes "months to years long delay" for applicants
- Moodle learning management system committed but EMS applications not fully developed
- No established quality indicators or formal program for monitoring course delivery
- No formal needs assessment conducted
- ETT program widely taught in remote communities; ETTs "sometimes the only provider a patient will encounter"
- Perform workforce needs assessment with EMS Regions
- Adopt National EMS Education Standards for all levels
- Use NREMT testing once computer-based testing established in high schools/other sites
- Establish common criminal background check process for all levels
- Identify strategies for recruitment and retention; eliminate every-2-year testing requirement
- Build distance education products via Moodle for CE
- Require medical director course completion as prerequisite
3D. Essential Service Designation
Not documented in this report. The term "essential service" does not appear.3E. Regulatory Fragmentation
(a) Direct quotes:The Alaska State Medical Board has the responsibility for licensing Paramedics while the Unit handles certification of all other levels of EMTs and other regulatory functions in the EMS system. This split in the state oversight of EMS personnel represents an inconsistency in the State's protection of the public served by EMS." (Regulation and Policy, p.11)
In 2014, Alaska has arrived at a point where its statutes, regulations and plans are out of date and out of step with national guidelines that are building increased unity among EMS systems elsewhere in the nation." (Regulation and Policy, p.12)
The lack of clarity and ability to enforce reasonable regulations sets up an attitude of indifference." (Regulation and Policy, p.12)(b) Data points:
- Paramedic licensing: Alaska State Medical Board (causing months-to-years delays)
- All other EMT levels: EMS Unit certification
- Regulations last updated 2002; subsequent update attempts failed due to "procedural missteps"
- EMS Unit in Juneau; TSP and HERO in Anchorage — geographic separation limits coordination
- First responder services: NOT currently regulated by state; standards only in developmental stages
- EMT1 and ETT levels do not require medical direction
- No EMD certification despite Unit having authority
- Site inspections for 350+ vehicles not conducted due to resource limitations — "honor system" self-assessment every 2 years
- No emergency vehicle operations training required for ambulance drivers
- No quality indicators or formal monitoring of course delivery
- Legislature should transfer paramedic licensing from State Medical Board to Department
- Section should establish regulatory authority over ALL provider personnel, agency types, and vehicles
- Department should consolidate all Section programs to one geographic location (move EMS Unit to Anchorage)
- Complete first responder service certification requirements
3F. Data and Evaluation Systems
(a) Direct quotes:The Unit has established the statewide ePCR program, Aurora, and roughly 66 percent of agencies are submitting data through this system. This data submission captures nearly 90 percent of all EMS transports in the state." (Evaluation, p.38)
A formal process of evaluating the effectiveness of patient care and outcomes using this data has not yet been established." (Evaluation, p.38)(b) Data points:
- Aurora ePCR system: 66% of agencies submitting; captures ~90% of all EMS transports
- Over 25,000 patient care reports submitted to National EMS Database (NEMSIS) last year
- Preparing for transition to NEMSIS 3
- Alaska Trauma Registry (ATR): over 2 decades old; data required from and received by all 24 acute care hospitals; current and validated; full-time trauma registrar; recently transitioned to web-based product
- ATR data being linked to Alaska Crash database via Highway Safety 408/405 grant
- Aurora-ATR linkage scheduled for early 2015
- No formal QA/QI process for EMS system performance
- No statutory protection from discovery for QA activities
- EMSC Assessment: 96% response rate — used to guide program focus
- Aurora data reviewed for: response times, bariatric patients, transports by provider impression
- No mechanism to provide feedback to EMS agencies on performance and outcomes
- Legislature should ensure statutory protection from discovery for all QA functions
- Develop comprehensive outcome evaluation program for time-sensitive emergencies
- Pursue mechanism for all certified agencies to submit to Aurora
- Develop mechanism for first responder data submission
- Develop feedback mechanism for agencies on performance and outcomes
3G. Trauma System Status
(a) Direct quotes:Trauma remains a significant public health issue that taxes Alaska's EMS system." (Trauma Systems, p.35)
Alaska having the highest rate of occupational fatalities in the United States and their rank of third in highest mortality due to injury." (Trauma Systems, p.35)
With the inclusion of the closest regional resource level I trauma center, Harborview (Seattle, WA), 55 percent of Alaska's population are within 1 hour of a level I or II trauma center." (Trauma Systems, p.35)(b) Data points:
- 13 designated trauma centers: 1 Level II, 12 Level IV
- Additional Level II expected (Anchorage hospital); 3 Level IV centers expected to upgrade to Level III
- Level I resource: Harborview Medical Center, Seattle, WA (out of state)
- 55% of population within 1 hour of Level I or II (including Harborview)
- 24 acute care hospitals; nearly all have received trauma verification or consultation visits
- ACS Trauma System Consultation received 2008; numerous recommendations realized
- ATR: data from all 24 hospitals; full-time registrar; web-based; validated
- No pediatric specialty hospitals, burn centers, or stroke centers in Alaska
- 2 hospitals in Anchorage perform PCI (cardiac specialty)
- Some acute care hospitals have chosen NOT to participate as designated trauma centers
- In Anchorage: "the accepted trauma dictum of bringing the severely injured patient to the closest appropriate facility is not being followed"
- Clinics often first to receive/stabilize serious patients in remote areas
- Telemedicine links available between many clinics and hospitals
- No burn, stroke, or STEMI center designation standards
- Continue implementing 2008 ACS Trauma System Consultation recommendations
- Customize trauma field triage for Anchorage area
- Develop initial system performance indicators
- Develop designation standards for specialty centers (stroke, STEMI)
3H. Medical Direction
(a) Direct quotes:The formal structure of how trauma and preparedness receive appropriate medical input is not clear." (Medical Direction, p.32)
There is not, however, a formal relationship between the state medical director and the regional medical directors." (Medical Direction, p.32)
On-line medical direction is very difficult because of the limited communication infrastructure and vast geography of the state." (Medical Direction, p.33)
The quality of individual agency standing orders is diverse and non-standardized." (Medical Direction, p.33)(b) Data points:
- State EMS Medical Director: EXISTS — contracted emergency physician; regulatory responsibilities for standards/guidelines; consultative role for trauma/preparedness (hours cut)
- 7 regional medical directors — roles/responsibilities NOT outlined in regulation; involvement varies
- State Medical Director meets annually with regional medical directors — no formal relationship
- EMT1 and ETT levels do NOT require medical direction
- First responder agencies: unregulated, no medical direction
- Agency medical directors required for agencies above EMT1; responsible for protocol approval, chart review, destination criteria
- State scope of practice established per level; agency medical directors can expand scope with Unit approval
- In emergencies, physicians can instruct EMTs to perform any procedure regardless of certification
- Online medical direction difficult due to communications infrastructure limitations
- Standing orders diverse and non-standardized; model guidelines from Unit "do not appear to be updated regularly"
- QA activities NOT protected from discovery
- Medical director charge does not include agency or system performance improvement
- Two Anchorage PICU hospitals offered online medical control for pediatric patients statewide
- Online medical director course available but "not widely used"
- Legislature should ensure statutory protection for QA activities
- Section should clearly define in regulation roles/responsibility/authority of State and Regional Medical Directors
- ACEMS should establish medical director subcommittee
- Require medical direction for ALL certified provider levels including EMD and ETT
- Publish updated evidence-guided treatment guidelines and pursue mandatory use
- Establish mandatory trauma triage and destination criteria for time-sensitive emergencies
- Require medical director course as prerequisite
3I. Communications and Infrastructure
(a) Direct quotes:Only 70 percent of the population of the state have access to 911 or E911." (Communications, p.28)
In more remote areas, requests for EMS assistance may come via CB radio to the Community Health Aide (CHA/P) in a local clinic or similar less formal mechanisms." (Human Resources, p.20)(b) Data points:
- 70% of population has access to 911 or E911
- Alaska Land Mobile Radio (ALMR) system: covers most roadways but not statewide; concerns about future charges and incomplete coverage
- 4 communications trailers strategically located (ALMR, CB radio, handheld radios, HAM radios, satellite phones, interoperability)
- VHF MEDNET radios in remote areas
- State Enterprise Technology Services responsible for statewide interoperability plan
- HERO program manager represents EMS Unit on state interoperability committee
- No EMD training or certification provided by state despite Unit having authority
- No EMD personnel certified
- EMD regulations "loosely monitored and enforced"
- No medical oversight for EMD personnel or dispatch systems
- Web-based medical resource platform for bed availability/patient tracking — well used in urban, less in remote areas
- Remote areas may use CB radio for EMS requests
- Cell phone coverage inconsistent
- Legislature should fund gaps in emergency healthcare communications and ALMR integration
- Create communications committee to identify/prioritize needs
- Require EMD training and certification for personnel taking medical calls and dispatching ambulances
- Update state EMS communications plan using preparedness assessment
3J. Preparedness
(a) Direct quotes:Alaska has fully committed to this effort through the creation of the HERO program within the Section." (Preparedness, p.40)(b) Data points:
- HERO program administers PHEP and HPP grants
- Alaska Medical Station: scalable 250-bed "low acuity" field hospital for surge decompression
- Pharmaceutical caches, Strategic National Stockpile maintained
- 4 portable communications systems for frequency patching
- "Alaska Shield" exercise: simulated large-scale earthquake (1964-type scenario)
- HERO has responded to floods and wildfires on numerous occasions
- Department is ESF8 lead agency for all-hazard health/medical response
- Health Operation Center can activate with state EOC
- START triage system used statewide
- Web-based patient tracking platform available statewide
- Statewide EMS pandemic influenza plan exists
- Integration between Unit, TSP, and HERO "not been fully realized"
- Maximize organizational structure by ensuring full integration of HERO, TSP, and EMS
- Develop standardized medical protocols for major medical incidents
- Maintain current inventory of patient transport resources and certified personnel
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
This is a reassessment of the 1999 reassessment (15-year interval).
Alaska has made little if any progress on updating its EMS statutes, regulations and plans since the 1999 EMS Reassessment." (Regulation and Policy, p.11)Key progress documented since 1999:
- ACS Trauma System Consultation received (2008); numerous recommendations realized
- 13 trauma centers designated (1 Level II, 12 Level IV)
- Nearly all 24 hospitals received trauma verification or consultation visits
- Alaska Trauma Registry maintained with data from all 24 hospitals; web-based
- Aurora ePCR system established; 25,000+ records submitted to NEMSIS
- HERO program created for preparedness
- Code Blue program established and maintained
- Alaska Medical Station (250-bed field hospital) developed
- 4 communications trailers strategically deployed
- EMS for Children Assessment achieved 96% response rate
- Regulations updated in 2002 (but not since)
- EMS statutes, regulations, and plans NOT updated since 1999 (regulations updated 2002 only)
- EMS Goals document (plan) not updated "in many years"
- Subsequent regulatory update efforts failed due to "procedural missteps"
- Paramedic licensing still split between Medical Board and EMS Unit
- Written exam "partially compromised and of questionable validity"
- No EMD certification despite authority
- No site inspection process for 350+ vehicles
- No discovery protection for QA
- No formal workforce needs assessment
- National EMS Education Standards not adopted
- Standing orders non-standardized
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall characterization:This setting that is Alaska challenges the design of an EMS system." (Introduction, p.8)
Alaska's EMS patients cannot afford for the system to be anything less than well organized, well resourced, carefully coordinated and operated under a model of continuous quality improvement." (Introduction, p.8)
The people who are Alaska's EMS providers have given their hearts and souls to make their system work in an incredibly difficult environment." (Introduction, p.8)
A failure to make progress in this essential element will continue to impede all other efforts to improve the system, potentially leading to less than optimal care or less than standardized care of vulnerable EMS patients." (Regulation and Policy, p.12)
The lack of progress in these important areas has strained relationships and is testing the good will of important system constituents." (Regulation and Policy, p.11)Structural barriers identified:
- Geographic separation of EMS Unit (Juneau) from TSP/HERO (Anchorage)
- Paramedic licensing split between Medical Board and EMS Unit
- Statutes, regulations, and plans out of date since 1999/2002
- Failed regulatory update attempts due to procedural missteps
- No dedicated funding source — annual general fund allocations only
- 30% of population without 911 access
- Limited communications infrastructure making online medical direction difficult
- Lack of discovery protection for QA
- "Honor system" self-assessment replacing site inspections
- Leadership turnover within the Unit
The report explicitly frames EMS within the healthcare continuum. The 2006 IOM Report referenced in Background. Introduction describes EMS as part of a "system of care" that "blends tradition with modern high-tech medicine." The CHAP integration is a healthcare model.
Federal funding mechanisms:- Highway safety funds referenced as original TAT mechanism
- EMSC program supported the assessment
- Highway Safety 408/405 grant funding for ATR-crash data linkage
- PHEP and HPP grants administered through HERO
- Code Blue leverages other grant funds
- No Section 402 funds specifically named
- 7 EMS regions (501(c)(3) nonprofits) — "cornerstones of EMS in Alaska" since the 1970s
- Community Health Aide Program (CHAP) — "great example of combining programs"
- Alaska Trauma Registry: all 24 hospitals reporting, data current and validated
- HERO program and Alaska Medical Station (250-bed field hospital)
- Innovative patient transport solutions (PTVs, sleds, snow machines, boats, four-wheelers)
- Strong injury prevention programs (Kids Don't Float, citizen CPR, gun safety, fall prevention)
- EMSC Assessment: 96% response rate
- NEMSIS submission of 25,000+ records
- Resourcefulness and commitment of providers
- Cultural integration (Inupiat values, CHAP model)
- Highest occupational fatality rate nationally; third in injury mortality
- "Little if any progress" on statutes/regulations/plans since 1999
- Code Blue funding "woefully inadequate" for remote systems
- Written exam "partially compromised and of questionable validity"
- 30% of population without 911 access
- No EMD certification despite authority
- No site inspections — "honor system" only
- Geographic separation of Section programs
- Declining volunteerism
- Non-standardized standing orders
- No formal QA/QI process; no discovery protections
- Paramedic licensing delays (months to years)
- Strained relationships due to lack of regulatory progress
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
Inupiat Values and Cultural Integration
The report opens with a statement of Inupiat values — "Knowledge of Language, Sharing, Respect for Others, Cooperation, Respect for Elders, Love for Children, Hard Work" — and frames them as tenets the Alaska EMS system "would be wise to keep in mind." This cultural integration is unique in the corpus. The CHAP model and the blending of traditional knowledge with modern medicine are presented as distinctively Alaskan.
Patient Transport Vehicles (PTVs) and Alternative Transport
Alaska uses "patient transport vehicles" — modified trucks with bolted boxes (~$80,000 with tires and radios) that can switch between tires and tracks seasonally. Also documented: sleds, snow machines, modified boats, and four-wheelers. This is the only state in the corpus where non-ambulance transport modes are the norm rather than the exception for much of the state.
Harborview (Seattle) as Level I Trauma Resource
Alaska's trauma system calculations include Harborview Medical Center in Seattle, Washington as the nearest Level I trauma center resource — 55% of Alaska's population within 1 hour of a Level I/II only when this out-of-state facility is included. No Level I trauma center exists in Alaska.
Highest Occupational Fatality Rate Nationally
Alaska has the highest rate of occupational fatalities in the United States and ranks third in highest mortality due to injury. This is the most acute injury burden documented in the corpus.
"Little If Any Progress" Since 1999
The TAT's statement that "Alaska has made little if any progress on updating its EMS statutes, regulations and plans since the 1999 EMS Reassessment" — covering a 15-year interval — is among the most direct characterizations of stagnation in the corpus. Failed regulatory updates attributed to "procedural missteps" compounded the problem.
Compromised Written Exam
The state-developed certification exam is "acknowledged to be partially compromised and of questionable validity" — creating "significant legal exposure" for the State. This finding has no parallel in other assessed states.
30% Without 911 Access
Only 70% of Alaska's population has access to 911 or E911. In remote areas, EMS requests may come via CB radio to a Community Health Aide in a local clinic. This is the lowest 911 coverage rate documented in the corpus.
250-Bed Field Hospital
The Alaska Medical Station — a scalable 250-bed "low acuity" field hospital for decompressing major medical facilities during mass casualty events while patients await transport to the contiguous U.S. — is a unique preparedness asset reflecting Alaska's isolation.
Seven Regional Nonprofits Since the 1970s
The 7 EMS regions structured as 501(c)(3) nonprofit corporations, operational since the 1970s, represent one of the oldest and most autonomous regional EMS structures in the nation. They were described as having assumed some state-level roles during Unit leadership transitions.
Analysis produced using standardized NHTSA State EMS Assessment extraction framework. All quotes are from the Alaska 2014 Reassessment report. No editorial synthesis applied.
California
Full Analysis
California 1999 NHTSA State EMS Assessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of California
- Report type: Assessment
- Date of site visit: August 23–26, 1999
- Year of publication: 1999
- Prior assessment year: N/A (initial assessment)
- TAT members:
- Alasdair K.T. Conn, M.D., FACS — Chief, Emergency Services, Massachusetts General Hospital; Chair, Massachusetts Committee on Trauma; Chair, Boston Medflight Helicopter Inc.
- Drew Dawson — Chief, Health Systems Bureau, Montana Department of Public Health and Human Services; President, NASEMSD; Board of Directors, National Registry of EMTs
- Dia Gainor — Chief, Emergency Medical Services Bureau, Idaho Department of Health and Welfare; President Elect, NASEMSD
- Susan D. McHenry — EMS Specialist, NHTSA (NHTSA facilitator); Former Director, Virginia Office of EMS; Past President, NASEMSD
- Ronald G. Pirrallo, M.D., MHSA, FACEP — Associate Professor of Emergency Medicine, Medical College of Wisconsin; Director of Medical Services, Milwaukee County EMS
- NHTSA facilitator: Susan D. McHenry
- Number of presenters/briefings: Over 35 presenters
- Requesting agency: Emergency Medical Services Authority (EMSA), in concert with the Office of Traffic Safety
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not explicitly stated numerically. The report references California's "huge landmass and population" (p. 29) and notes the trauma regulation standard of one Level I or II center per 350,000 population served (p. 27).
- Geographic characteristics: The report describes "huge landmass," "varied geography and population densities" (p. 29). Rural highways referenced in Background section (56% of fatalities occur on rural highways nationally). No square mileage cited.
- Number of counties/jurisdictions: Not explicitly counted. The report references multiple Local EMS Agencies (LEMSAs) — some multi-county, some single-county — and six mutual aid and administrative regions for disaster purposes (p. 32).
- EMS system overview:
- Governance structure: Deeply decentralized. EMSA is the state authority; LEMSAs are responsible for local system coordination. The State EMS Commission (16 members) is the primary advisory body and approves EMSA regulations (p. 8). The formal relationship between EMSA and LEMSAs is "not always clearly defined and understandable to all of the participants" (p. 7).
- EMSA Director: Vacant (persistent vacancy). Richard Watson serving as Interim Director (p. 4, 10).
- State EMS Medical Director: No state EMS medical director. EMSA has contracted with two EMS physicians for medical input and disciplinary issues (p. 8).
- Number of agencies/providers: Not enumerated. The report references 26 paramedic training organizations (p. 13), over 350 PSAPs (p. 19), and "literally hundreds of combinations of training standards and certification processes and agencies" for EMT-I level (p. 13).
- Notable demographic or socioeconomic factors cited: The report opens with California's role as a national trendsetter and references the "turbulent change in the health care delivery system" (p. 5), the interaction of EMS with managed care systems, hospital emergency department overcrowding, ambulance diversion, and the closure of emergency facilities. SB 1953 mandating seismic retrofitting or closure of hospital acute care facilities by 2008 is cited as a significant infrastructure concern (p. 32).
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:he absence of a comprehensive state EMS plan is more evident as a result of the Vision process than ever before." (p. 10)
There is currently no statewide EMS plan" (p. 15)
no comprehensive statewide plan or program exists for EMS system evaluation, quality improvement, data collection or data utilization." (p. 29)
The report documents a collaborative planning effort — the "Vision" process — that produced "Shaping the Future of EMS in California":
The EMSA and its many partners are to be commended for undertaking the Vision process. 'Shaping the Future of EMS in California' is a significant collaborative effort which will guide California's EMS system into the next millennium." (p. 7)
The major EMS constituents have voluntarily agreed to a temporary moratorium on the introduction of EMS legislation to allow completion of the vision process." (p. 7)(b) Specific data points: No statewide EMS plan exists. LEMSAs are required to develop local EMS plans but their congruence with statewide planning is unclear (p. 10). The "Vision" document has been developed but represents stakeholder perspectives, not a formal plan. (c) TAT characterization: The absence of a plan is described as a fundamental gap, made more evident — not less — by the Vision process itself. The Vision process is commended as a meritorious accomplishment but is explicitly insufficient as a substitute for a plan. (d) Priority recommendation: Yes (bold italics, p. 8):
The EMS Authority, in collaboration with its EMS partners, should develop a state EMS plan.
3B. Funding and Financial Sustainability
(a) Direct quotes:The state and local EMS system has fragile funding support." (p. 8)
The state EMS Authority is predominantly supported by state general fund and by the federal Preventive Health and Health Services Block grant, the continuation of which may be tentative." (p. 8)
While the EMSA provides some level of funding for the multi-county EMS regions, funding for single county LEMSAs is even more tenuous. They may receive funding from up to 12 different sources including the county, tobacco tax dollars and motor vehicle violations." (p. 8)
LEMSA's share of tobacco tax revenue has been consistently declining as have their moving traffic violation dollars." (p. 8)
EMSA has few dollars allocated to fund research." (p. 30)(b) Specific data points:
- EMSA funded primarily by state general fund and federal PHHS Block Grant
- LEMSAs may receive funding from up to 12 different sources
- Tobacco tax revenue to LEMSAs: consistently declining
- Moving traffic violation revenue to LEMSAs: declining
- EMSA has secured competitive grants including EMSC
- PHHS Block Grant funds provided to LEMSAs for PI&E objectives
- No dedicated, stable EMS funding mechanism documented
- No specific dollar amounts, budgets, or appropriations cited anywhere in the report
The EMS Authority and counties should pursue adequate and stable funding for local EMS agencies and for the state EMS Authority for administration, system planning and evaluation activities.
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:An inconsistent, if not dysconjugate, distribution of roles between the EMSA and LEMSA exist depending on the source or level of training or the level of certification/licensure being sought." (p. 13)
The greatest diversity can be found at the EMT-I level, wherein training and ultimately certification/licensure can occur through literally hundreds of combinations of training standards and certification processes and agencies." (p. 13)
There is no assurance that an EMT-I certified by one LEMSA is equivalent to an EMT-I certified by another LEMSA." (p. 7)
investigation and disciplinary processes for EMT-Is and EMT-IIs varies among LEMSAs." (p. 13)
he extent to which recruitment and retention issues are contributing factors is not evident." (p. 13)(b) Specific data points:
- 26 paramedic training organizations
- All paramedic training programs must be accredited by the Joint Review Committee by 2004
- National Registry examination used exclusively for paramedic licensure
- EMT-I certification/licensure: "literally hundreds of combinations"
- No statewide minimum scope of practice for EMT-I or EMT-II (p. 24)
- No EMD certification/licensure
- No statewide requirements for emergency vehicle operator training
- Specific workforce numbers (vacancies, counts, attrition): not documented
The EMSA should require the use of US Department of Transportation (USDOT) National Standard Curricula at all levels.
The EMSA should develop and introduce uniform and consistent statewide certification/licensure of all prehospital personnel.
The EMSA should standardize EMT-I and EMT-II certification/licensure examination standards.
EMSA should promulgate regulations establishing Emergency Medical Dispatcher as a level of EMS certification/licensure.
3D. Essential Service Designation
(a) Direct quotes: Not documented in this report. The phrase "essential service" does not appear. (b) Specific data points: N/A (c) TAT characterization: The report does not address essential service designation. The institutional status of EMS is addressed through the framework of statewide standardization, lead agency authority, and EMSA-LEMSA relationships, but not through the essential service lens. (d) Priority recommendation: N/A — not addressed.3E. Regulatory Fragmentation
(a) Direct quotes:Since the inception of EMS in California, local agencies have played a pivotal role in EMS system development. While county-by-county regulation of EMS evolved, there was frequently no inter-county or statewide coordination." (p. 6)
This decentralized approach has historically enabled the development of local EMS systems that have addressed local needs and spawned many of California's innovative EMS programs." (p. 6)
he current regulations and policies are lacking in statewide uniformity, consistency and enforcement." (p. 7)
There are neither appropriate rules and regulations for each component of the emergency medical services system nor system-wide standards for treatment, transport, communications or interfacility transport." (p. 7)
There is no statewide licensure of out-of-hospital emergency medical services providers. There is no assurance that all ambulance services meet minimum standards throughout the state." (p. 7)
While there are minimum standards for private ambulance vehicles, these standards are not applicable to public ambulance services." (p. 7)
The formal, legal relationship between the EMS Authority and the LEMSA is not always clearly defined and understandable to all of the participants." (p. 7)
he actions and responsibilities of LEMSAs apparently vary considerably from LEMSA to LEMSA." (p. 7)
Multiple agencies (EMSA, CHP, LEMSAs and others) are responsible for developing and ensuring compliance with laws, regulations, standards and guidelines pertaining to these services. This fragmentation of authority appears to result in a lack of coordination of regulatory oversight." (p. 15)(b) Specific data points:
- EMSA created 1980
- State EMS Commission: 16 members
- Over 350 PSAPs
- 26 paramedic training organizations
- LEMSAs: number not specified, but referenced as both single-county and multi-county, varying "considerably"
- No statewide licensure of EMS providers
- No statewide ambulance inspection process
- Public ambulance services exempt from minimum standards that apply to private services
- Guidelines exist but "do not have the force of regulations" (p. 7)
- San Bernardino California Supreme Court decision referenced as example of jurisdictional disputes (p. 7)
The EMS Authority should aggressively pursue consistent statewide standardization and coordination of treatment, transport, communications and evaluation.
Also bold italics (pp. 8–9):
There should be consistent and uniformly enforced regulations (not guidelines) for EMS provider service licensing, facility designation, EMS personnel licensing and medical direction.
There should be uniform statewide licensing of all levels of EMS services (providers) including public, private and air medical services.
There should be uniform and consistent statewide licensing of all EMS prehospital personnel.
3F. Data and Evaluation Systems
(a) Direct quotes:no comprehensive statewide plan or program exists for EMS system evaluation, quality improvement, data collection or data utilization." (p. 29)
even current State EMS system performance guidelines (e.g., response time criteria) are not being scrutinized." (p. 29)
Current statewide EMSA quality improvement tasks are delegated to one employee." (p. 29)
submission of data to a central state agency is infrequent and the little information received by the state is not compiled or analyzed." (p. 30)
he common practice that the patient care record is not left at the receiving hospital when the patient is delivered. Vital prehospital patient care information may be lost to the emergency department and subsequent care givers." (p. 30)
data linkages do not exist among PSAPs, dispatch communication centers, EMS responders and hospitals." (p. 30)
ality improvement activities do have confidentiality and disclosure protection under state law, it does not extend to EMS providers." (p. 30)(b) Specific data points:
- No statewide EMS data collection system
- No statewide QI program
- 1 employee assigned to statewide QI tasks at EMSA
- A minimum statewide patient care data set exists for EMT-II and paramedic providers but use varies by LEMSA
- Patient care records commonly not left at receiving hospitals
- No data linkages among PSAPs, dispatch, EMS responders, and hospitals
- QI confidentiality protection does not extend to EMS providers (only hospitals)
- No statewide trauma registry in operation (required by new regulations but not yet implemented)
- No statewide human subject review process for EMS research
- EMSA has legislative authority to evaluate but has not exercised it
Develop a comprehensive, medically directed statewide quality improvement program to evaluate patient care processes and outcomes.
Develop a statewide integrated information system (as described in the Vision document) that will have the capability to monitor, evaluate and elucidate emergency medical services and trauma care in California.
Allocate personnel and resources to implement the statewide integrated information system including necessary technical assistance, materials and funding to LEMSAs.
The EMSA should write, and help shepherd through the legislative process, legislation to assure confidentiality and non-discoverability of EMS and trauma records and EMS provider protection while participating in EMS QI activities.
3G. Trauma System Status
(a) Direct quotes:The State of California has recently promulgated comprehensive regulations concerning the California trauma system." (p. 27)
These regulations are to be implemented within each LEMSA over the next two years unless that LEMSA has a comprehensive trauma plan already in place." (p. 27)
These criteria bear close resemblance to the national criteria developed by the Committee on Trauma of the American College of Surgeons." (p. 27)
While the new trauma system regulations are excellent, there are system wide deficiencies which may make the coordinated development of a statewide trauma system difficult." (p. 28)(b) Specific data points:
- New comprehensive trauma regulations recently promulgated; implementation timeline: 2 years
- Standard: one Level I or II center per 350,000 population served
- Regulations cover: 4 adult trauma center levels, pediatric trauma center criteria, data collection, system evaluation, QI, interfacility transfer
- Trauma registry required by regulation; protected under Evidence Code Section 1157.7
- No mandatory autopsy requirement
- No statewide trauma registry in operation
- Limited state staff with clinical expertise for trauma system coordination
- No statewide multidisciplinary trauma committee
- No mechanism to translate trauma QI findings to statewide policy changes
- Specific number of designated trauma centers: not documented in the report
Funding should be ensured that the components of the new regulations can all be implemented by both the EMSA and the LEMSA to ensure that a true statewide system plan can be realized.
3H. Medical Direction
(a) Direct quotes:The State of California has been without EMS physician leadership more than 50% of the time during the past 19 years." (p. 24)
There is currently no state EMS Medical Director; however, the EMS Authority has contracted with two EMS physicians to provide medical input and to assist the Authority with disciplinary issues." (p. 8)
No formal standing medical committee is available to advise the EMSA or EMS Commission." (p. 24)
No statewide minimum scope of practice has been established for EMT-I or EMT-II providers. No statewide minimum patient care standards, treatment protocols or triage guidelines exist for any level of EMS provider." (p. 24)
Significant variation exists between LEMSAs regarding patient care protocols and an EMS provider's scope of practice." (p. 24)
Of more concern is the lack of standard qualifications, commitment, compensation and involvement of the medical director in LEMSA decision making." (p. 24)
No resources are available to orient or prepare a physician for their role as a LEMSA or provider agency medical director." (p. 25)
No evidence exists of statewide physician oversight of concurrent or retrospective review of out-of-hospital emergency medical care, the establishment of optimal system performance indicators or ongoing quality improvement programs." (p. 25)(b) Specific data points:
- No state EMS Medical Director (>50% of past 19 years without one — i.e., since EMSA creation in 1980)
- Two contract physicians providing limited medical input
- No formal standing medical advisory committee
- No statewide minimum patient care standards, treatment protocols, or triage guidelines for any level
- No statewide minimum scope of practice for EMT-I or EMT-II
- No qualifications standards for LEMSA or provider agency medical directors
- No training or orientation resources for new medical directors
- No statewide QI physician oversight
- EMS Medical Directors Association of California (EMDAC) described as "committed, expert EMS physicians who are an underutilized resource by the EMSA" (p. 25)
The position of the state EMS medical director should be created with a clearly defined role and legislative authority and responsibility for EMS system standards, protocols and evaluation of patient care.
A standing medical advisory committee should be established.
A statewide minimum scope of practice should be established for all levels of EMS providers.
Statewide minimum patient care standards, treatment protocols and triage guidelines should be established for all levels of EMS providers.
EMSA should define a mechanism to provide physician oversight to review patient care, establish performance indicators and development of ongoing quality improvement programs in the state EMS plan.
Medical oversight and patient care standards should be developed for interfacility transports.
3I. Communications and Infrastructure
(a) Direct quotes:9-1-1 calls are answered by over 350 PSAPs." (p. 19)
There is no state EMS communications plan." (p. 19)
A variety of EMS communications systems are used (VHF, UHF, 800 MHz), but much of the equipment is now outdated and in need of replacement." (p. 19)
There is no statewide public safety communications system or frequency allocation plan. This causes enormous problems with interagency operability." (p. 19)
The Department of General Services (DGS) telecommunications office is currently working on a statewide public safety communications system plan which is predominantly oriented toward state agencies... More importantly, this plan does not address EMS communications." (p. 19)
There are no Emergency Medical Dispatch standards" (p. 19)
The Police Officers Standards of Training (POST) requires that law enforcement dispatchers have only 4 hours of EMS Dispatcher training." (p. 20)(b) Specific data points:
- Over 350 PSAPs
- Most of state has enhanced land line 9-1-1
- CHP answers all wireless 9-1-1 calls
- CHP dispatchers: no EMD training
- Law enforcement dispatchers: 4 hours of EMS dispatcher training required by POST
- No state EMS communications plan (draft report exists but not circulated)
- No statewide public safety communications system
- No frequency allocation plan
- 1 EMSA position responsible for EMD programs and communications technical assistance
- EMD regulations under development
- Communications systems: VHF, UHF, 800 MHz — outdated, need replacement
The EMSA should coordinate closely with the Department of General Services in the planning and implementation of a statewide public safety agency telecommunications system and should make a concerted effort to assure the inclusion of emergency medical services in that plan.
The EMSA should continue to assess EMS communications needs, do EMS communications planning, provide technical assistance to LEMSAs and attempt to secure funding to improve the state EMS communications infrastructure.
Emergency Medical Dispatch should become an EMS personnel certification/licensure level and should be required of EMS dispatch centers.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
N/A — This is an initial assessment, not a reassessment.SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization of the EMS system:The Introduction adopts an exceptionally laudatory opening tone, positioning California as a national and global trendsetter:
As goes California, so goes America; as goes America, so goes the world." (p. 5)
Prehospital advanced life support and the development of regional trauma programs together with the data that first demonstrated their effectiveness in reducing preventable death all had their start in California." (p. 5)
where would the public's knowledge of EMS be without the TV show 'Emergency' and the expertise of Johnny and Roy." (p. 5)
The tone then shifts to acknowledge uncharted territory:
Many of the problems that are being faced by California in these times of turbulent change in the health care delivery system have yet to be faced by other regions." (p. 5)
The interaction of EMS with managed care systems, the challenge of delivering emergency care to the rapid influx of emergency patients when hospitals are on ambulance diversion and operating at occupancy with high acuity patients - these are situations where there are no known answers." (p. 5)Structural barriers identified:
The report identifies multiple structural (not merely resource or implementation) barriers:
- No state EMS Medical Director for more than 50% of EMSA's 19-year existence
- Persistent vacancy in the EMSA Director position
- EMSA-LEMSA relationship not clearly defined in law
- Guidelines lack force of regulations; LEMSAs have not consistently adopted them
- No statewide licensure of EMS providers; public ambulances exempt from private ambulance standards
- No QI confidentiality protection for EMS providers
- No statewide minimum patient care standards, protocols, or triage guidelines for any provider level
- Jurisdictional disputes (San Bernardino Supreme Court decision)
- DGS statewide communications planning excludes EMS
- SB 1953 seismic mandate threatens hospital infrastructure
The report reflects the transportation framework in its Background section:
NHTSA is charged with reducing accidental injury on the nation's highways." (p. 1)
But the body of the report operates primarily within a healthcare framework. The Introduction references EMS as part of the "health care delivery system" and "health care revolution" (p. 5). The report discusses managed care interactions, hospital ED overcrowding, ambulance diversion, EMTALA compliance, and pediatric intensive care — all healthcare system concepts. The Vision document is framed as health system planning.
Federal funding mechanisms referenced:- Highway safety funds — assessment program funding mechanism (p. 1)
- Federal Preventive Health and Health Services Block Grant — primary federal funding for EMSA; continuation described as "tentative" (p. 8)
- EMSC grants — secured competitively by EMSA (p. 8)
- Office of Traffic Safety (OTS) funding — supported EMSA injury prevention programs since 1991 (p. 22); funded additional epidemiologist at DHS (p. 22)
- PHHS Block Grants — distributed to LEMSAs for PI&E objectives (p. 22)
- Tobacco tax dollars — declining revenue source for LEMSAs (p. 8)
- Historical pioneering role in prehospital ALS and regional trauma programs
- Vision process — "Shaping the Future of EMS in California" as collaborative planning effort
- Comprehensive new trauma regulations ("excellent")
- EMSC program and pediatric EMS integration
- National Registry examination for paramedic licensure
- Training requirements for non-traditional providers (bus drivers, child care workers, lifeguards, law enforcement) — "commendable"
- Individual LEMSA medical directors establishing "local centers of excellence"
- EMDAC as a committed physician resource
- Sophisticated local information systems at some LEMSAs
- Disaster preparedness — "impressive depth of preparation"
- Statewide 9-1-1 access
- Liability protection statute
- No state EMS Medical Director (>50% of EMSA existence)
- Persistent vacancy in EMSA Director position
- No statewide EMS plan
- No statewide minimum patient care standards, protocols, or triage guidelines for any provider level
- No statewide licensure of EMS providers or services
- "Fragmentation of authority" in regulatory oversight
- No statewide EMS data system; 1 employee assigned to QI
- Fragile, declining funding at both state and local levels
- No statewide EMS communications plan; outdated equipment
- Over 350 PSAPs with interoperability problems
- Hospital ED overcrowding, ambulance diversion, facility closures
- Patient care records not reaching receiving hospitals
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. Scale of the system. California in 1999 presents the largest and most complex EMS system assessed by NHTSA to that point. The report's descriptions — "huge landmass and population," "daunting volume of personnel," "literally hundreds of combinations" of training standards — convey a system operating at a scale that may exceed the capacity of the assessment format itself. The TAT added an 11th component (Disaster Systems) at the state's request, the only such addition documented in this analysis corpus.
2. "Dysconjugate" — clinical precision in institutional diagnosis. The TAT uses the medical term "dysconjugate" (p. 13) to describe the EMSA-LEMSA distribution of roles in human resources — a term meaning eyes that do not move together. This clinical metaphor is unique in the NHTSA assessment corpus and precisely captures the finding: two entities looking at the same patient from different directions.
3. State medical director absent >50% of EMSA's existence. The finding that California has been without EMS physician leadership for more than half of the 19-year existence of its EMS authority (p. 24) is among the most striking structural findings in any NHTSA assessment. This is not a temporary vacancy but a chronic institutional condition.
4. EMSA Director position persistently vacant. The report documents that both the Director and Medical Director positions are vacant simultaneously, with only an Interim Director and contract physicians. The TAT states:
The likelihood of long term success of the state EMS planning efforts or any other meaningful EMS system advancements is threatened until this compromise is corrected." (p. 10)
5. Public/private ambulance regulatory asymmetry. The report documents that minimum vehicle standards apply to private ambulance services but not to public ambulance services (p. 7). This two-tiered system means that government-operated ambulances may not meet the standards imposed on private operators.
6. Patient care records not reaching hospitals. The report identifies "the common practice that the patient care record is not left at the receiving hospital when the patient is delivered" (p. 30) — a finding with direct patient safety implications that goes beyond system-level evaluation concerns.
7. Managed care interaction as emerging frontier. The report explicitly identifies the interaction of EMS with managed care systems and hospital overcrowding/diversion as problems "where there are no known answers" (p. 5). This positions California as facing health system challenges that other states had not yet encountered in 1999.
8. Legislative moratorium. The major EMS constituents agreed to a voluntary moratorium on EMS legislation to allow the Vision process to complete (p. 7) — an unusual institutional dynamic where stakeholders self-impose a legislative pause.
9. Emergency department overcrowding and ambulance diversion. The report documents hospitals downgrading capabilities, emergency facilities closing, remaining facilities becoming "increasingly overwhelmed," decreasing specialist availability, high occupancy contributing to diversion, and ambulance crews unable to transfer patients — delaying return to service (pp. 17–18). A task force involving ACEP-California, CMA, and CHA had formed to address this (p. 17). This represents an early documentation of what would become a national crisis.
10. Seismic mandate threatening hospital capacity. SB 1953 mandating retrofitting or closure of non-compliant hospital acute care facilities by 2008, following estimates of potential 50% hospital bed loss in a major earthquake (p. 32), represents a unique intersection of disaster planning, hospital infrastructure, and EMS system capacity.
11. TV show "Emergency" cited in official NHTSA assessment. The TAT Introduction references the television show "Emergency" and its characters "Johnny and Roy" as contributors to public EMS awareness (p. 5) — a unique cultural reference in the formal assessment literature.
12. "As goes California, so goes America." The opening line of the Introduction (p. 5) explicitly frames California's EMS challenges as national harbingers. The TAT positions the state's problems — managed care interaction, ED overcrowding, ambulance diversion — as challenges other states will eventually face. This characterization elevates the report from a state assessment to a prospective national briefing.
Analysis extracted: February 2026. Source document: State of California, An Assessment of Emergency Medical Services, NHTSA Technical Assistance Team, August 23–26, 1999.
Colorado
Full Analysis
Colorado 1997 NHTSA State EMS Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of Colorado
- Report type: Reassessment
- Date of site visit: November 11–13, 1997
- Year of publication: 1997
- Prior assessment year: 1988 (December 13–15, 1988) — Colorado was the first state in the nation to request an assessment.
- TAT members:
- Theodore R. Delbridge, MD, MPH, FACEP — Assistant Professor of Emergency Medicine, University of Pittsburgh; Operations Medical Director, City of Pittsburgh EMS; Medical Director, STAT MedEvac; Principal Investigator, EMS Agenda for the Future
- Dan Manz — EMS and Injury Prevention Director, Vermont Department of Health; Past President, NASEMSD; Co-Chair, EMS Agenda for the Future
- Kimball Maull, MD, FACS — Division of Trauma, Loyola University; Past President, American Trauma Society; Past Vice Chairman, ACS Committee on Trauma; Senior Reviewer, ACS Trauma Center Verification Program
- Susan McHenry — EMS Specialist, NHTSA (NHTSA facilitator); Former Director, Office of Emergency Medical Services, Virginia Department of Health; Past President, NASEMSD
- Timothy Wiedrich — Director, Division of Emergency Health Services, North Dakota Department of Health; President Elect, NASEMSD
- NHTSA facilitator: Susan McHenry
- Number of presenters/briefings: Over 25 presenters
- Requesting agency: Colorado Department of Transportation, Office of Transportation Safety, in concert with the Colorado Department of Public Health and Environment, Emergency Medical Services and Prevention Division
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not explicitly stated in the report.
- Geographic characteristics: The report describes Colorado as covering over 104,000 square miles, with much of the land mass characterized as "isolated, rural, frontier territory" (p. 16). The Introduction describes the state as "rugged mountains that spill onto open plains" symbolizing "diversity and challenge" (p. 5).
- Number of counties/jurisdictions: Not explicitly stated. The report references county-level regulation of ambulance services and county-level E-911 implementation.
- EMS system overview:
- Governance structure: Decentralized. The EMS and Prevention Division within the Colorado Department of Public Health and Environment operates programs but lacks statutory lead agency authority. State EMS Advisory Council and Trauma Advisory Council exist (being consolidated). Area Trauma Advisory Councils (ATACs) are in place.
- Program Director: Michael Armacost, Program Director
- State EMS Medical Director: Dr. Ben Honigman (also serves as Medical Director of the State Trauma System)
- Number of agencies/providers: Not enumerated. Report references more than 160 EMS Physician Advisors (p. 28). 18 designated trauma centers. Quick Response Teams (QRTs) referenced but not counted.
- Notable demographic or socioeconomic factors cited: The report emphasizes a "frontier spirit that values individual freedom" (p. 5) and notes this cultural value directly influences EMS system structure. "Prop 2½"-style local autonomy is not referenced, but decentralized county control is a central theme.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:A comprehensive plan for the development of a coordinated EMS system for Colorado was developed and published in 1992." (p. 10)
Since that time, impressive progress on some goals and objectives has occurred, while little movement has taken place for others. The plan has not been updated since its initial publication." (p. 10)
In Colorado, the evaluation formed the basis of a state EMS plan that has guided improvements for nearly a decade." (p. 5)(b) Specific data points: A statewide EMS plan was published in 1992, based on the 1988 assessment. It has not been updated in 5 years as of the reassessment. (c) TAT characterization: The TAT acknowledges the plan's role in guiding improvements but identifies its lack of updating as a gap. The plan's existence is treated as a significant achievement of the prior assessment period. (d) Priority recommendation: The recommendation to update the plan is standard-weight (p. 11). However, the broader recommendation to establish a statutory lead agency (bold, p. 8) encompasses the planning function.
3B. Funding and Financial Sustainability
(a) Direct quotes:Establishment of a dedicated EMS funding program" (p. 7, listed as an accomplishment since 1988)
The Highway Users Transportation Fund (HUTF) provides a sustained revenue stream that allows EMS providers throughout the state to improve their vehicles, equipment, communications and other necessities." (p. 11)
Concern was expressed that the HUTF is becoming an EMS entitlement program and that the financial resources of the fund are not being allocated to the current areas of greatest need within the EMS system." (p. 11)
The current formula for disbursing funds does not provide the flexibility necessary to assure an adequate EMS system infrastructure." (p. 11)
Funding for the system is singularly absent." (p. 30, regarding the trauma system)(b) Specific data points:
- Highway Users Transportation Fund (HUTF): Dedicated EMS funding source established by legislation in 1989; used for vehicles, equipment, communications, county ambulance regulation, and the EMS program within the Department
- Specific dollar amounts for HUTF: not documented
- Trauma system funding: described as "singularly absent" (p. 30)
- No other specific budget figures, appropriations, or dollar amounts cited in the report
Secure adequate personnel and financial resources to perform the necessary lead agency functions. Those financial resources could include but are not limited to the use of private foundations, general funds, user fees, and an expansion of the current dedicated funding source or the identification of other dedicated funding sources.
Also bold (p. 12):
The Colorado legislature should remove the percentage constraints contained in the Highway Users Transportation Fund statute and establish an administrative procedure to distribute the funds to areas of greatest need.
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:An effort is currently underway to analyze the status of EMS personnel recruitment and retention within the state. The intended purpose of this work is to develop strategies that will enable EMS organizations to more reliably maintain a qualified workforce." (p. 11)
Currently, in Colorado, primary ambulance services are required to staff vehicles to the level of advanced first aid. Consistency in staffing vehicles with a minimum of at least one EMT-Basic has not been realized." (p. 14)
The state has begun a process to identify recruitment and retention issues affecting EMS personnel through the funding of a three part study assessing personnel needs, volunteer efforts and interventions or barriers to overcoming identified retention and recruitment problems." (p. 13)(b) Specific data points:
- Minimum ambulance staffing level: advanced first aid (not EMT-Basic)
- More than 160 EMS Physician Advisors statewide
- A three-part recruitment/retention study was funded (personnel needs, volunteer efforts, barriers)
- Specific vacancy numbers, graduation rates, or attrition rates: not documented
Require at least one certified EMT-Basic on all emergency ambulances within the state.
Establish the standards and criteria for first responder training and certification (both individual and training programs), within the State EMS lead agency.
3D. Essential Service Designation
(a) Direct quotes: Not documented in this report. The report does not use the phrase "essential service" in reference to EMS designation. (b) Specific data points: N/A (c) TAT characterization: The report does not explicitly address essential service designation. However, the recurring theme of needing a statutory lead agency with comprehensive authority implicitly addresses the institutional status of EMS. The report also notes:he state does not have authority to assure the provision of quality EMS to the public" (p. 8)(d) Priority recommendation: N/A — not addressed by this term, though the lead agency recommendation encompasses this concern.
3E. Regulatory Fragmentation
(a) Direct quotes:Colorado has an EMS system which divides regulatory and policy responsibility among multiple governmental organizations. These responsibilities include the regulation of ambulance services by counties, Emergency Medical Technicians (EMTs) and trauma systems by the State Department of Health, and EMS medical directors and EMT scope of practice issues by the Board of Medical Examiners." (p. 7)
Creation of EMS regulation and policy is excessively decentralized, resulting in impediments to improvement and EMS system disparities throughout the state." (p. 8)
Substantial differences exist, for example, in the regulation of ambulance services across the state." (p. 8)
No statutory authority exists at any level to regulate air medical transportation and non-transporting EMS agencies." (p. 8)
Basic questions regarding the profile of Colorado's EMS system cannot be answered." (p. 8)(b) Specific data points:
- At least 3 distinct regulatory entities: counties, State Department of Health, Board of Medical Examiners
- County-level ambulance regulation with no statewide standards
- No authority to regulate air medical transportation at any level
- No authority to regulate non-transporting EMS agencies
- 3 pilot regional cooperation programs initiated
- State Patrol consolidating dispatch from 18 into 5 regional centers
A state EMS lead agency should be statutorily established to coordinate implementation of the EMS system. That state EMS lead agency should have statutory authority to address regulation and policy; resource management; human resources and training; transportation; facilities; communications; public information, education and prevention; medical direction; trauma systems and evaluation.
3F. Data and Evaluation Systems
(a) Direct quotes:Despite efforts to implement data collection systems, progress in the area of evaluation has been disappointing. None of the recommendations have been effectively addressed." (p. 32)
Colorado has abandoned attempts to institute a statewide, centralized prehospital data collection system." (p. 32)
The Prehospital Care Program is currently unable to reliably evaluate EMS structures, processes, or outcomes, as it does not have a statewide data base." (p. 33)
The state lacks the infrastructure necessary to conduct meaningful EMS evaluation. There is no information system." (p. 33)
here is no confidentiality conferred upon EMS evaluation results, unless the activities evaluated occur within the confines of a hospital." (p. 32)(b) Specific data points:
- No statewide prehospital data collection system
- Prior attempts at centralized data collection: abandoned
- No statewide EMS database
- No QI confidentiality protection for EMS (only hospital-based activities protected)
- A minimum prehospital data set is being developed (work underway, not completed)
- Trauma registries exist at Level I–III trauma centers via CTI
- Colorado Hospital Association provides outcome data from Level IV and nondesignated facilities
- Zero of the 1988 evaluation recommendations effectively addressed (p. 32)
The State EMS Division must develop a strategy for EMS system evaluation. This must be included in future EMS planning. Evaluation is a mandatory activity to determine the effectiveness of the statewide EMS system and to validate future directions of EMS system development.
Statewide EMS evaluation should include structural (capacity of the system), process (activities of the system), and outcomes (effects of the system) components.
The State EMS Division should finalize adoption of a minimum EMS data set which includes elements to be collected for every EMS response in the state.
The Division must implement a system for statewide EMS data collection.
3G. Trauma System Status
(a) Direct quotes:The trauma system is on the launch pad." (p. 30)
Due in part to the early efforts of the Colorado Trauma Institute, and efforts of the Department and the Trauma Advisory Council most of the essentials for system development now exist. Funding for the system is singularly absent." (p. 30)
Trauma system enabling legislation was passed in 1995." (p. 30)(b) Specific data points:
- Trauma center designation began in 1991 using ACS-COT verification
- 18 designated trauma centers: 3 Level I, 6 Level II, 8 Level III, 1 Level IV
- Level I–III verified by ACS-COT; Level IV verified by Colorado Trauma Institute (CTI)
- CTI trauma registry in place tracking: trauma type with outcome, injury causation, age/gender distribution, geographic distribution by county, temporal demographics, alcohol involvement, discharge destination, injury severity with outcome
- Enabling legislation passed 1995
- Area Trauma Advisory Councils (ATACs) in place
- Trauma system funding: "singularly absent"
- System described as an inclusive model
The State EMS Division should implement the statewide trauma system per the 1995 legislative mandate.
The State EMS Division should provide adequate staffing and funding to support implementation of the statewide Trauma System.
The State EMS Division should continue to provide leadership and a collaborative approach to bringing facilities and personnel on board as team players in the inclusive system.
The State EMS Division should view total needs of the state in context of those facilities expressing interest in designation; if needed, encourage facilities in critical shortage areas to improve their trauma care capabilities.
3H. Medical Direction
(a) Direct quotes:Dr. Ben Honigman is the current State EMS Medical Director, and has served in that role for the past three years. He now also serves as the Medical Director of the State Trauma System, which enhances the influence of medical leadership at the state level." (p. 27)
Unfortunately, the State EMS Medical Director position is not based in statute and enjoys no legislative authority. There is some concern regarding its potential lack of permanence in the Division." (p. 27)
Colorado must be commended for its vision in requiring EMTs at all levels to have medical direction and is a leader in the nation in establishing this important standard." (p. 8)
However, EMS Physician Advisors may independently determine the practice parameters for their EMS personnel. Anecdotally, these parameters may occasionally far exceed the capabilities of prehospital care providers." (p. 28)
Local protocols are not routinely scrutinized and there is no ongoing system of monitoring or pursuing quality improvement for EMS Physician Advisors." (p. 28)
no statewide regulation exists that requires EMS agencies to have a Physician Advisor" (p. 28)(b) Specific data points:
- State EMS Medical Director: funded since 1990, serving 3 years as of 1997
- Position is not based in statute, has no legislative authority
- More than 160 EMS Physician Advisors statewide
- More than 50% of Physician Advisors have attended the voluntary one-day Physician Advisor Course (offered since 1991)
- Medical Advisory Group formed 1995, recognized by Board of Medical Examiners as formal liaison committee 1996
- No requirement for EMS agencies (as opposed to individual providers) to have a Physician Advisor
- No ongoing monitoring or QI system for Physician Advisors
- Emergency medicine residents (PGY 2+) used to fill rural Physician Advisor gaps, supervised by State EMS Medical Director
The Department of Health and Environment should institutionalize the position of State EMS Medical Director, ensuring the permanence of the position and its source of funding.
The Division and the Board of Medical Examiners should require that all EMS activities are conducted with appropriate medical direction. This should include, but not be limited to, activities of emergency medical dispatchers, EMS first response agencies, and EMS patient-transporting agencies.
3I. Communications and Infrastructure
(a) Direct quotes:The Colorado EMS communications system is characterized by numerous unlinked subsystems, each with different designs and technology." (p. 21)
The lack of a common approach to system design results in problems with the provision of on-line medical direction and coordination among responder agencies. It also increases the cost of communications and decreases reliability." (p. 21–22)
Cellular telephones have become the default route of EMS communication for field to hospital linkages. Since cellular service is not complete statewide, there are numerous gaps in this system as well." (p. 22)
patients arriving at hospitals without giving pre-notification and mass casualty incidents where responder agencies cannot communicate with one another." (p. 22)(b) Specific data points:
- Most counties have implemented Enhanced 9-1-1; all but 1 remaining county in process
- State Patrol consolidating dispatch from 18 centers into 5 regional centers
- A digital trunked radio system (DTRS) plan was completed and published in June 1995
- DTRS phase-in could begin as early as 1998, pending legislative funding
- Telecommunications Services provides a statewide microwave system
- Number of PSAPs: not documented
- Cellular coverage: incomplete, unreliable during peak times
Telecommunications Services should facilitate development of the communications section of the State EMS plan. Improvements in the EMS communications system should not be dependent on the statewide trauma system.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (1988 Assessment)
The report systematically addresses prior recommendations in each of the ten component sections under "Progress on Meeting 1988 Recommendations" subsections.
Documented as Completed or Substantially Accomplished:
- Creation of a statewide EMS plan (1992)
- Planning for a trauma system including statutory authority (legislation passed 1995)
- Establishment of a funded state EMS medical director within the Department (since 1990)
- Development of a strategy to address EMS personnel recruitment and retention
- Establishment of a voluntary medical director training program (Physician Advisor Course since 1991)
- Removal of fees associated with EMS personnel certification
- Development of voluntary air medical service guidelines
- Establishment of a dedicated EMS funding program (HUTF, legislation 1989)
- Identification of status of statewide 911 access (survey performed)
- Implementation of a voluntary emergency medical dispatch program
- Establishment of a Public Information and Education program (position established, program since 1993)
- Designation of 18 trauma centers using ACS-COT verification (began 1991)
- CTI trauma registry established
- ATACs in place
- Upgrade of ambulance vehicles and equipment via HUTF grants
- Development of a uniform ambulance inspection form
- CISM network established
Documented as Not Completed:
- Establishing a comprehensive EMS legislation providing statutory authority for a State EMS lead agency (p. 7)
- Creation of standardized medical control and direction (p. 7)
- Standardization of ambulance licensing (p. 7)
- Human resource needs assessments (p. 13)
- On-line medical direction for prehospital personnel (p. 13)
- Pre-established and standardized policies, procedures and protocols for EMS personnel and agencies (p. 13)
- Routine audit capability of EMS activities statewide (p. 13)
- Adequate state, local or regional infrastructure staffing and system automation for evaluation (p. 13)
- Statewide standards for inspection and licensing of all modes of emergency medical transportation (p. 16)
- Statewide needs assessment including ambulance placement and deployment guidelines (p. 16)
- Statewide ambulance licensing and inspection standards (p. 16)
- Ambulance driver training (p. 16)
Evaluation — Complete Failure:
Despite efforts to implement data collection systems, progress in the area of evaluation has been disappointing. None of the recommendations have been effectively addressed." (p. 32)
This is the only component where the TAT explicitly states that none of the prior recommendations were effectively addressed.
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization of the EMS system:The TAT adopts a respectful, at times lyrical tone while delivering substantive structural criticism. The Introduction celebrates Colorado's pioneering role:
In 1988, Colorado was the first state in the nation to request an assessment of its EMS system. The product of that process shaped what has become a widely recognized tool for evaluating and improving state EMS systems throughout the nation." (p. 5)
Now is a time to reflect, to celebrate past accomplishments, examine where we are, and look boldly to the future." (p. 5)
One accomplishment that stands out is the high regard the EMS Division has earned, largely due to its ability to accurately gauge the sophistication and dedication of EMS providers throughout the state." (p. 5)
Yet the structural diagnosis is blunt:
Despite the progress of the past decade, much remains to be done. Some of the barriers to progress that existed ten years ago are still present today." (p. 5)Structural barriers identified:
The report identifies the following as structural (not merely resource or implementation) barriers:
- Absence of a statutory EMS lead agency with comprehensive authority
- Excessive decentralization of regulatory authority across counties, Department of Health, and Board of Medical Examiners
- No authority to regulate air medical transportation or non-transporting agencies at any level
- State EMS Medical Director position not based in statute
- HUTF distribution formula locked by legislative percentage constraints
- No QI confidentiality protections outside hospital settings
- Inability to answer basic questions about the EMS system's profile
The report explicitly bridges both frameworks. The Background section reflects NHTSA's transportation mandate:
NHTSA is charged with reducing accidental injury on the nation's highways." (p. 1)
But the 1997 standards are updated to reflect the healthcare framework:
The standards now reflect current EMS philosophy and allow for the evolution into a comprehensive and integrated health management system, as identified in the 1996 EMS Agenda for the Future." (p. 1)
This is a notable transitional moment — the report explicitly references the 1996 EMS Agenda for the Future as the new philosophical framework, and TAT member Ted Delbridge was the Principal Investigator of that document.
Federal funding mechanisms referenced:- Highway safety funds — referenced as the funding mechanism for the TAT assessment program (p. 1)
- Highway Users Transportation Fund (HUTF) — state-level dedicated EMS funding from transportation revenues (pp. 11, 16)
- EMS-C funding — supported PIER program inception in 1993 (p. 24); funded two half-time EMS-C Injury Prevention Specialists (p. 25)
- No direct references to Section 402 funds, though HUTF derives from highway user revenues
- First state to request NHTSA assessment (1988) and second to request reassessment (1997)
- Dedicated EMS funding source (HUTF) — "one of the most important initiatives since the last assessment" (p. 16)
- Requirement for medical direction at all EMT levels — "a leader in the nation" (p. 8)
- 18 designated trauma centers with ACS-COT verification and CTI registry
- Exemplary PIER program with extensive accomplishments
- Active CISM network
- Near-universal E-911 coverage
- Innovative use of emergency medicine residents for rural medical direction
- High regard for the EMS Division
- No statutory EMS lead agency
- Excessively decentralized regulation
- Complete failure in evaluation/data collection (zero prior recommendations addressed)
- No statewide prehospital data system (abandoned prior attempts)
- Trauma system legislatively authorized but unfunded
- State EMS Medical Director position not in statute
- No minimum EMT-Basic staffing requirement on ambulances
- Fragmented communications system with unlinked subsystems
- HUTF distribution formula inflexible
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. First-in-the-nation status. Colorado was the first state to request a NHTSA EMS assessment (1988) and the second to request a reassessment (1997). The TAT explicitly notes that the 1988 Colorado assessment "shaped what has become a widely recognized tool for evaluating and improving state EMS systems throughout the nation" (p. 5).
2. EMS Agenda for the Future explicitly referenced. The 1997 reassessment standards are described as reflecting "current EMS philosophy and allow for the evolution into a comprehensive and integrated health management system, as identified in the 1996 EMS Agenda for the Future" (p. 1). TAT member Theodore Delbridge was the Principal Investigator of that document, making this reassessment a direct vehicle for the Agenda's implementation philosophy.
3. "Excessively decentralized" — unusually strong language. The characterization of Colorado's regulatory structure as "excessively decentralized" (p. 8) is notably direct for NHTSA assessment language, which typically uses more diplomatic phrasing.
4. Ambulance staffing below EMT-Basic. Colorado is documented as requiring ambulance staffing only to the level of "advanced first aid" — below even the EMT-Basic threshold (p. 14). The TAT's bold recommendation to require at least one EMT-Basic on all emergency ambulances implies that, as of 1997, some Colorado ambulances responded to emergencies staffed by personnel with only advanced first aid certification.
5. Complete evaluation failure. The explicit statement that "none of the recommendations have been effectively addressed" in the Evaluation component (p. 32) and that the state has "abandoned" centralized data collection (p. 32) is an unusually stark finding. Among all ten components, evaluation is the only one where the TAT documents zero progress on any prior recommendation.
6. HUTF as "entitlement program." The TAT's characterization of the dedicated funding source as trending toward an "entitlement program" (p. 11) rather than needs-based allocation identifies a structural incentive problem within an otherwise successful funding mechanism.
7. Frontier spirit as structural determinant. The TAT explicitly links Colorado's cultural identity to its EMS system structure: "A frontier spirit that values individual freedom has brought Colorado to where it is and will clearly influence its future" (p. 5). This framing attributes regulatory fragmentation not solely to legislative oversight but to a conscious cultural choice.
8. Report structure evolution. The TAT explicitly notes a shift in approach between assessment and reassessment: "Unlike the state's initial assessment which contained many operational recommendations, several of which were identified as a priority, this report offers fewer yet broader recommendations that the team believes to be critical for continued system improvement" (p. 2). This reflects a maturation in the NHTSA assessment methodology itself.
9. Three regional cooperation pilot programs. The report documents three pilot programs promoting regional cooperation among counties by providing a staff resource (p. 11). The TAT characterizes these as "a creative step towards building on the existing model of local control" and recommends monitoring them as "an intermediate step towards statewide regulation of ambulance services." This represents an incremental strategy designed to work within Colorado's decentralized culture.
10. Trauma system described as "on the launch pad." The metaphor is distinctive — conveying a system with all prerequisites in place but unable to ignite due to funding absence. The TAT states that "Funding for the system is singularly absent" (p. 30), using "singularly" to emphasize funding as the sole remaining barrier.
Analysis extracted: February 2026. Source document: State of Colorado, A Reassessment of Emergency Medical Services, NHTSA Technical Assistance Team, November 11–13, 1997.
Connecticut — 2 Reports
Full Analysis
Connecticut 2000 NHTSA State EMS Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of Connecticut
- Report type: Reassessment
- Date of site visit: June 6–8, 2000
- Year of publication: 2000
- Prior assessment year: 1991
- TAT members:
- Thomas J. Esposito, MD, FACS — Associate Professor of Surgery, Chief, Section of Trauma, Loyola University Medical Center; Director for Injury Analysis and Prevention Programs, Loyola University Shock Trauma Institute
- Mark E. King — Director, West Virginia Office of EMS; Treasurer, NASEMSD; NREMT-P
- Jon R. Krohmer, MD, FACEP — Medical Director, Kent County EMS; Director of EMS, Emergency Medicine Residency, Spectrum Health; Associate Professor, Michigan State University; President, NAEMSP
- Susan McHenry, MS — EMS Specialist, NHTSA (NHTSA facilitator); Former Director, Virginia Office of EMS; Past President, NASEMSD
- W. Daniel Manz — EMS Director, Vermont Department of Health; Past President, NASEMSD; Co-Chair, EMS Agenda for the Future
- NHTSA facilitator: Susan McHenry, MS
- Number of presenters/briefings: More than 56 presenters
- Requesting agency: Connecticut Department of Public Health, in concert with the Connecticut Department of Transportation, Division of Highway Safety
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not explicitly stated.
- Geographic characteristics: The report describes Connecticut as having "small geographic size" with "disparity of population distribution" (p. 5). No square mileage cited.
- Number of counties/jurisdictions: 169 municipalities. The report explicitly notes the absence of viable county government: "The municipal, rather than county form of government, disparity of population distribution and proud independence makes the delivery of Emergency Medical Services a rather complex undertaking" (p. 5). The report also states: "The lack of viable county level government has made regionalization of service delivery and other programs difficult" (p. 11).
- EMS system overview:
- Governance structure: OEMS reports directly to the Office of the Commissioner (recently elevated). Five regional EMS councils with clearly defined roles and performance contracts. State EMS Advisory Board and Medical Advisory Committee both active. 169 municipalities each required to develop a local EMS plan (new legislation).
- Commissioner: Dr. Joxel Garcia, MD, MBA (appointed May 1999)
- OEMS Director: Position recently reestablished and filled (had been abolished mid-1990s)
- State EMS Medical Director: Part-time (0.4 FTE), contractual, surgery-trained; roles outlined in contract but not in legislation; no formal delineation of authority
- Number of agencies: 192 ambulance companies serving 169 municipalities; 13 CMEDs; 108 PSAPs; 31 general acute care hospitals; 5 satellite emergency care facilities
- OEMS staffing: Increased from 8 to 13 FTEs
- Notable demographic or socioeconomic factors cited: The report emphasizes Connecticut's "fiercely independent" population and strong tradition of local government as the defining structural characteristics. The state experienced a major institutional disruption in the mid-1990s when the OEMS was downsized, the Director position abolished, and regulatory functions reassigned.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:A comprehensive statewide EMS plan was developed in 1997 and updated in 1999." (p. 10)
Connecticut has a statewide EMS plan that addresses both adult and pediatric emergency care." (p. 10)
In light of new legislation and other structural changes within the Department of Public Health, the plan should be reviewed for any necessary updates." (p. 10)
he state recently passed legislation that requires each of the 169 municipalities to develop a local EMS plan." (p. 8)(b) Specific data points: A statewide EMS plan exists (developed 1997, updated 1999). Five regional councils submit annual work plans as contractual deliverables. 169 municipalities now required to develop local EMS plans. (c) TAT characterization: Connecticut has achieved what most assessed states lack — a statewide EMS plan addressing both adult and pediatric care. The TAT acknowledges this accomplishment but notes it needs updating in light of recent structural and legislative changes. (d) Priority recommendation: Yes (bold, p. 8):
Review, revise and implement the State EMS Plan
Also bold (p. 11):
Review, revise and implement the statewide EMS plan in light of recent legislative changes and a new Office of EMS structure within the Department of Public Health
3B. Funding and Financial Sustainability
(a) Direct quotes:Information provided to the TAT indicated that the EMS budget was projected to increase 35% by 2001." (p. 8)
In the near future, the CMEDs will receive a per capita subsidy for the services they provide." (p. 21)
Not all volunteer agencies charge for service." (p. 17)
Actual budgetary needs related to the [PI&E] program were unclear." (p. 23)(b) Specific data points:
- EMS budget: projected 35% increase by 2001
- DPH responsible for ambulance rate setting and Certificate of Need (CON)
- EMS equipment and local system development grant program administered by OEMS
- Per capita CMED subsidy forthcoming
- Specific dollar amounts, appropriations, or budget figures: not documented
- Funding for data collection/evaluation system: questions raised about availability (p. 34)
- Trauma system: no dedicated funding identified (p. 31)
- UHF radio system replacement: estimated cost "in the tens of millions of dollars" (p. 22)
Assure stable, ongoing funding for OEMS to carry out its mission and implement its programs
Also bold (p. 8):
Eliminate the rate setting and CON requirements for EMS in law and regulation
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:Many ambulance services are small, predominantly volunteer corps. It was reported that service management is an issue of concern in some areas." (p. 11)
The state has not yet committed to a minimum crew level of two EMTs, due to the implications in rural, mostly volunteer, areas of the state." (p. 13)
These variable requirements were noted as a deterrent to volunteerism." (p. 14)
here is interest in identifying barriers to EMT training for potential volunteers and developing methods to provide incentives, recruitment and retention programs and other methods to maintain the EMS workforce." (p. 14)(b) Specific data points:
- Minimum ambulance crew: 2 certified EMS providers (EMT and MRT), not two EMTs — a compromise due to rural volunteer implications
- MRT (Medical Response Technician) program expanded statewide, used by law enforcement and fire personnel
- Training programs conducted through community colleges, hospitals, public safety academies, local EMS agencies, and individual instructors
- Not all certification levels use national-level testing
- Specific vacancy numbers, attrition rates, provider counts: not documented
Standardize training for all levels of providers based on National Standard Curricula
3D. Essential Service Designation
(a) Direct quotes: Not documented in this report. The phrase "essential service" does not appear. (b) Specific data points: N/A (c) TAT characterization: The report does not address essential service designation. However, the requirement for all 169 municipalities to develop local EMS plans implicitly treats EMS as a municipal responsibility without formally designating it as an essential service. (d) Priority recommendation: N/A — not addressed.3E. Regulatory Fragmentation
(a) Direct quotes:The municipal, rather than county form of government, disparity of population distribution and proud independence makes the delivery of Emergency Medical Services a rather complex undertaking." (p. 5)
The lack of viable county level government has made regionalization of service delivery and other programs difficult." (p. 11)
he model of 169 individual communities planning their EMS delivery is a strong example of local involvement, it clearly does not support the concept of resource sharing and economies of scale." (p. 11)
Similar to other EMS operations in CT, the PSAPs are highly decentralized and do not enjoy the operating efficiencies generally associated with large volume centers." (p. 22)
A state program exists to encourage PSAP consolidation which provides grant funding as an incentive. Despite this inducement, little interest in consolidation has been generated." (p. 22)(b) Specific data points:
- 169 municipalities (no county government)
- 192 ambulance companies
- 108 PSAPs
- 13 CMEDs
- 5 regional EMS councils
- 31 acute care hospitals plus 5 satellite facilities
- 14 designated trauma centers in Connecticut plus 1 in Massachusetts
- EMS functions within DPH split between OEMS and Division of Health Systems Regulations
- PSAP consolidation incentive grants offered; "little interest" generated
Promote regionalization at all levels of the EMS system to reduce duplication and increase operating efficiencies" (p. 12)
Promote regionalization of transport services to reduce duplication and increase operating efficiency" (p. 17)
Promote the consolidation of PSAPs as part of a broad effort to decrease costs while improving the efficiency and quality of services through regionalization" (p. 22)
3F. Data and Evaluation Systems
(a) Direct quotes:Many individuals providing testimony to the TAT indicated that data collection and evaluation is the most significant issue that must be addressed by the EMS system." (p. 34)
It is generally acknowledged that there is a lack of effective data collection which prohibits any meaningful system or organization evaluation in an effort to support the impact of the EMS system on patient care." (p. 34)
Because of the limitation of useful data, evaluation has not occurred to allow changes in policy, procedures and protocols based on that information." (p. 33)
he participants still need to complete the preliminary evaluation process step of determining specifically what outcome information is desired from the process (e.g., What questions do you want answered?)" (p. 34)(b) Specific data points:
- No statewide EMS data collection system (legislation PA 00-151 passed requiring one by October 2001)
- First response agencies: compliance required by October 2006
- Reporting requirements in legislation described as "relatively rudimentary" (p. 34)
- Some data collected by individual agencies, sponsor hospitals, trauma centers, regional councils — cannot be integrated
- Connecticut Hospital Association: 20 years of in-patient hospital data; houses trauma registry (currently not active)
- CODES project collecting some patient outcome data (without prehospital data)
- Multiple trauma registry software products in use across the state — inter-system incompatibilities
- No prehospital QI confidentiality/non-discoverability protection (hospital peer-review is protected)
- QI for each sponsoring hospital is independent — no statewide guidelines, no consistent reporting to state
- 1 FTE effectively added for data management, registry development, and trauma system development
Define the desired outcome and output of the evaluation process
Phase in implementation of an EMS system evaluation plan based on identified priorities
Establish the time line and identified budget for implementation of all of the components of the evaluation plan in more detail
Within the Office of EMS, identify an EMS information specialist (e.g., data czar) with responsibility for overall coordination of the evaluation program
Provide protection from discoverability for peer review EMS quality improvement information
3G. Trauma System Status
(a) Direct quotes:Trauma care in the state takes place within a functional EMS system. Trauma care components are becoming more clearly and integrally related to the overall EMS system through a growing combination of regulation, consensus and cooperation at the local, regional and state levels." (p. 29)
There appears to be a strong and active state trauma committee." (p. 29)
This appears to be an open designation process." (p. 30)
The trauma registry is not currently a useful tool for system monitoring and improvement." (p. 30)(b) Specific data points:
- Trauma system regulations enacted October 1995
- 14 Connecticut hospitals and 1 Massachusetts hospital designated as trauma centers (Levels I–III), using ACS verification
- Open designation policy — no consideration of resource distribution, volume, or need
- De-designation process exists and has been successfully employed once
- Trauma data dictionary created; data elements specified in legislation
- Independent consultant review of trauma registry conducted
- RFP planned for statewide trauma data system
- Preventable death study completed — may serve as needs assessment
- No dedicated trauma system funding identified
- No legislative QI confidentiality/non-discoverability protection for trauma or EMS data
Assure legislative protection for the confidentiality and non-discoverability of all data and the QI process
Identify and secure dedicated funding to support trauma systems improvemen
Request an ACS Trauma System Evaluation after implementation of the recommendations
3H. Medical Direction
(a) Direct quotes:The State Medical Director is surgery-trained but evolved his practice into emergency medicine and EMS activities. He has been the state medical director for several years. The roles and responsibilities of this 0.4 FTE position are outlined contractually, but are not included in legislation. There is no formal delineation of the State Medical Director's authority." (p. 26)
here are some MRT organizations which do not have a requirement for medical direction." (p. 26)
Although there is limited immunity offered in legislation for EMS personnel, this limited immunity does not extend to those providing medical direction." (p. 26)
The specific roles, responsibilities, and authority of the medical director are not currently defined as they relate to medical oversight of agencies and to EMD programs." (p. 26)
Each sponsoring hospital performs quality improvement activities for its agencies based on programs and criteria which each establishes independently. There are no statewide guidelines for those quality improvement programs and no regular or consistent reporting to the state." (p. 27)(b) Specific data points:
- State EMS Medical Director: 0.4 FTE, contractual, roles not in legislation, no formal authority
- No liability protection for medical directors
- Medical direction required for all prehospital agencies using advanced/invasive care, but not for some MRT organizations
- Sponsoring hospital model: each hospital identifies an EMS Medical Director (typically ED Medical Director)
- MIC (Mobile Intensive Care) Coordinators support medical directors at each sponsoring hospital
- Statewide BLS, ALS, and pediatric patient care guidelines developed, regularly reviewed — but local variations occur
- No statewide QI guidelines; no consistent reporting to state
- No EMD medical direction requirement in enabling legislation (though planned as programs develop)
- Base station training program "sporadically offered and attended" (p. 26)
Require that medical direction be provided for all levels of prehospital personnel and agencies regardless of whether they are providing basic or advanced level care.
Establish a legislated mechanism for limited liability protection for those individuals providing medical direction consistent with the limited liability protection available for EMS personnel.
Enhance the regulations regarding the roles, responsibilities and authority for the medical director, including activities such as credentialing, quality improvement, withholding medical oversight, and due process.
Establish statewide protocols for all levels of prehospital providers.
3I. Communications and Infrastructure
(a) Direct quotes:Connecticut is well served by a state of the art Enhanced 9-1-1 system for emergency services access. This is a second generation system recently implemented to replace the state's original E-9-1-1 system which was among the earliest in the nation." (p. 21)
The most significant threat to the integrity of EMS communications is an aging UHF radio system... Much of the current infrastructure is 20 or more years old and it is becoming increasingly difficult to find replacement parts." (p. 22)
The system is frequently congested, sometimes by users in adjacent states." (p. 22)
A complete upgrade or replacement of the system is estimated to cost in the tens of millions of dollars." (p. 22)(b) Specific data points:
- 108 PSAPs
- 13 CMEDs coordinating EMS communications from prehospital agencies to hospitals
- Second-generation E-911 system — "state of the art"
- UHF radio infrastructure: 20+ years old, parts increasingly unavailable
- Replacement cost estimate: tens of millions of dollars
- Standardized telecommunicator course leading to certification exists
- EMD not yet fully implemented (legislation PA 00-151 mandates statewide phase-in)
- Priority dispatch consistently available statewide
- CMED notification/dissemination of hospital diversion status: described as "exemplary"
- PSAP consolidation incentive grants: little interest generated
Develop a state communications plan including the identification of funding resources to update or replace the existing UHF radio system
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (1991 Assessment)
The report systematically addresses prior recommendations in each component section.
Documented as Completed or Substantially Accomplished:
- Trauma system regulations enacted (October 1995)
- DNR regulations enacted (1996)
- State EMS Advisory Board reestablished
- State EMS Medical Advisory Committee established
- OEMS elevated to report directly to Commissioner
- OEMS Director position reinstated
- Regional Council roles and responsibilities clearly defined with performance contracts
- Two certified EMS providers (EMT + MRT) required as minimum ambulance crew
- MRT program expanded statewide
- Educational programs (except EMT-I) use National Standard Curricula
- Most paramedic programs housed in post-secondary institutions
- Certification/recertification procedures streamlined
- Specialty education availability sufficient (PHTLS, ACLS, PALS)
- EMD training programs developing
- Two pediatric centers, one burn center, one hyperbaric oxygen center recognized
- Trauma center designation/de-designation process developed and implemented
- Trauma triage criteria developed and incorporated into regulation
- Second-generation E-911 system implemented
- Comprehensive statewide EMS plan developed (1997) and updated (1999)
- Data reporting legislation passed (PA 00-151)
- Sufficient vehicle inspection personnel
Documented as Not Completed or Partially Completed:
- Streamlining of regulatory process — OEMS completes its requirements timely but cannot control timelines of other state agencies and legislature (p. 6)
- Consistent statewide policies, procedures and protocols — not developed (p. 6)
- Patient transportation and destination plan — not developed (p. 16)
- Statewide data collection and evaluation system — legislation passed but not yet implemented (p. 10)
- Communications plan — no specific plan, only a section in the state EMS plan and a concept paper (p. 21)
- Coordination of CMEDs — not formally implemented, informal cooperation only (p. 21)
- Hospital capability evaluation for appropriate triage/destination — recommended in 1991 but "not felt to be a priority by any presenter" (p. 19)
- Two EMT minimum crew standard — not achieved due to rural volunteer implications (p. 13)
- Allowing municipalities and volunteers to charge for non-emergency transport — committee reviewed but determined premature due to lack of data (p. 16)
Notable finding on institutional disruption:
The Office was downsized in the mid 1990's and the position of EMS Director was abolished. The regulatory functions of EMS were assigned to the Division of Regulatory Services within the Department of Public Health. The EMS community struggled with the complex issues facing them without clear leadership from the state." (p. 5)
The mid-1990s dismantling of the OEMS and abolition of the Director position represents a period of institutional disruption between the two assessments, during which progress on many 1991 recommendations stalled.
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization of the EMS system:The report is structured as a narrative of institutional crisis, leadership intervention, and early recovery. The TAT frames the state's EMS trajectory in three phases:
Phase 1 — Post-1991 institutional dismantling:
The Office was downsized in the mid 1990's and the position of EMS Director was abolished... The EMS community struggled with the complex issues facing them without clear leadership from the state." (p. 5)
Phase 2 — Commissioner Garcia's intervention (May 1999):
Dr. Garcia brought to the position a sense of urgency, a vision, and strong leadership." (p. 5)
Phase 3 — Revitalization (2000):
Through Dr. Garcia's leadership, the stage has been set for significant improvements to take place in the Connecticut EMS System. While that stage has been set, the dedicated men and women involved in EMS throughout Connecticut will have to actively engage in the process to assure that the initiatives begun will be implemented." (p. 5)
The TAT's tone is cautiously optimistic — acknowledging significant recent progress while warning that implementation remains ahead.
Structural barriers identified:- Municipal governance without county government (169 independent municipalities)
- Resistance to regionalization despite incentive programs
- Split of EMS functions between OEMS and Division of Health Systems Regulations
- State Medical Director position contractual, part-time, without legislative authority
- No liability protection for medical directors
- No QI confidentiality protection for EMS (only hospital peer review)
- CON and rate-setting requirements described as cumbersome and ineffective
- Regulatory process delays outside OEMS control
The Background section reflects the standard NHTSA transportation framework:
NHTSA is charged with reducing accidental injury on the nation's highways." (p. 1)
The reassessment standards are described as reflecting "current EMS philosophy and allow for the evolution into a comprehensive and integrated health management system, as identified in the 1996 EMS Agenda for the Future" (p. 1).
The body of the report increasingly uses healthcare/public health language. The TAT recommends:
Continue integration of EMS within the public health system. Assure preservation of the traditional role of EMS for emergency response, and acknowledge its evolving role in community health improvement." (p. 11)
This is among the most explicit recommendations for EMS integration into public health in any NHTSA assessment.
Federal funding mechanisms referenced:- Highway safety funds — assessment program funding mechanism (p. 1)
- NHTSA, CDC, private foundations — referenced as potential PI&E funding sources (p. 23)
- No specific federal funding amounts or programs cited for EMS operations
- Commissioner Garcia's leadership — described as transformative
- Statewide EMS plan (developed 1997, updated 1999)
- Second-generation E-911 system — "state of the art," "among the earliest in the nation" originally
- Active State EMS Advisory Board and Medical Advisory Committee
- Five regional councils with clear roles and performance contracts
- Statewide BLS, ALS, and pediatric patient care guidelines
- Trauma center designation process using ACS verification (15 centers)
- CMED diversion notification described as "exemplary"
- Connecticut Hospital Association support (20 years of in-patient data, trauma registry)
- EMSC committee as standing committee of Advisory Board
- Statewide air medical coverage
- Relative wealth of medical resources
- 35% EMS budget increase projected
- No statewide EMS data collection system (acknowledged by stakeholders as "most significant issue")
- 169-municipality fragmentation without county government
- Aging UHF radio infrastructure (20+ years, tens of millions to replace)
- No QI confidentiality protection for EMS
- State Medical Director: 0.4 FTE, no legislative authority, no liability protection
- Medical direction not required for all provider levels
- Trauma registry currently non-functional
- No dedicated trauma system funding
- CON and rate-setting process cumbersome
- Resistance to regionalization and PSAP consolidation
- Open trauma center designation without resource distribution considerations
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. Institutional dismantling and recovery. Connecticut presents a unique case study of a state EMS office that was effectively dismantled mid-cycle between assessments. The OEMS was downsized in the mid-1990s, the Director position abolished, and the EMS community left "without clear leadership from the state" (p. 5). The appointment of Commissioner Garcia in May 1999 triggered a rapid reversal — within roughly one year, the Director position was reinstated, OEMS was elevated within DPH, staffing increased from 8 to 13 FTEs, significant legislation was passed, and the Advisory Board was reactivated. This narrative of collapse and rapid revitalization illustrates both the fragility and the recoverability of state EMS infrastructure when executive leadership intervenes.
2. 169 municipalities without county government. Connecticut's governmental architecture — 169 independent municipalities with no viable county government — creates a uniquely atomized EMS landscape. This is not regulatory fragmentation arising from unclear authority but a structural feature of the state's governmental design. The report's observation that this "clearly does not support the concept of resource sharing and economies of scale" (p. 11) while simultaneously being "a strong example of local involvement" (p. 11) captures the inherent tension.
3. Failed PSAP consolidation incentive. The state offered grant funding to incentivize PSAP consolidation, yet "little interest in consolidation has been generated" (p. 22). This is a documented case of a financial incentive failing to overcome structural and cultural resistance to regionalization — a finding with implications for other states pursuing similar strategies.
4. "Data czar" recommendation. The TAT recommends the creation of an "EMS information specialist (e.g., data czar)" within OEMS (p. 35) — distinctive language that emphasizes the need for a single point of authority for the evaluation program.
5. Medical director liability gap. EMS personnel have limited statutory immunity, but this protection does not extend to physicians providing medical direction (p. 26). This creates a structural disincentive for physician engagement in EMS oversight — physicians assume greater legal risk by participating in medical direction than the providers they oversee.
6. All patients must be transported to hospital. The report notes that "all transported patients can only be delivered to a hospital" and "there is no provision for a 'no response' decision" or "field decision of 'no transport required'" (p. 17). The TAT's bold recommendation to "investigate alternatives to the requirement to transport all patients to a hospital" (p. 17) identifies regulatory rigidity with system-level implications — a recommendation that prefigures the later community paramedicine and mobile integrated healthcare movements.
7. Certificate of Need for EMS. Connecticut's application of the Certificate of Need process to ambulance services is identified as cumbersome and ineffective (pp. 8, 11). The TAT recommends elimination of both CON and rate-setting for EMS — positioning these healthcare regulatory mechanisms as inappropriate for EMS service delivery.
8. EMS integration into public health. The TAT explicitly recommends continuing "integration of EMS within the public health system" while preserving "the traditional role of EMS for emergency response" and acknowledging "its evolving role in community health improvement" (p. 11). This is among the most direct statements of the public health integration concept in any NHTSA assessment from this period.
9. 1991 recommendation rejected by stakeholders. When the 1991 report recommended evaluating acute care hospital capabilities for appropriate triage/destination decisions, this recommendation was "not felt to be a priority by any presenter" nine years later (p. 19). This documents stakeholder resistance to a recommendation across a full assessment cycle.
10. 56 presenters — largest presenter count in this analysis corpus. The more than 56 presenters reflects broad EMS community engagement with the reassessment process, likely fueled by the recent revitalization energy under Commissioner Garcia.
11. Cross-state trauma designation. One Massachusetts hospital is designated as a Connecticut trauma center (p. 30), reflecting the interstate nature of trauma care in the small New England state — a practical accommodation that few other state assessments document.
Analysis extracted: February 2026. Source document: State of Connecticut, A Reassessment of Emergency Medical Services, NHTSA Technical Assistance Team, June 6–8, 2000.
Full Analysis
Connecticut 2013 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Connecticut
- Report type: Reassessment
- Date of site visit: July 30 – August 1, 2013
- Year of publication: 2013
- Prior assessment year: 2000 (Background, p.5: "reviewed the progress since the 2000 Reassessment")
- TAT members:
- Christoph R. Kaufmann, MD, MPH, FACS
- Ritu Sahni, MD, MPH, FACEP
- D. Randy Kuykendall, MLS
- Jolene R. Whitney, MPA
- NHTSA facilitator: Susan McHenry, MS
- Executive support: Janice D. Simmons, BFA
- Number of presenters/briefings: Over 30 presenters over the first day and a half (Background, p.5)
- Requesting agency: Connecticut Department of Public Health (DPH), Office of Emergency Medical Services (OEMS)
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not stated numerically; described as "the 29th most populous state in the union, yet the third smallest in size" with "a population density that is the fourth highest in the United States" (Introduction, p.8)
- Geographic characteristics: Third smallest state by area; fourth highest population density in the U.S.; 169 municipalities; 8 counties (counties lack infrastructure for EMS/fire/police services)
- Number of counties/jurisdictions: 169 municipalities (primary governance unit); 8 counties (non-functional for EMS); 5 EMS regions
- EMS system overview:
- 186 EMS services: 72 volunteer ambulance, 61 volunteer fire (remainder career/private)
- 655 ambulances, 101 invalid coaches, 2 helicopters, 2 boats, 7 MICI (non-transport intermediate), 177 MICP (medic non-transport)
- Over 23,000 certified/licensed providers at all levels
- Approximately 350,000 ambulance transports per year (over 500,000 ePCRs uploaded in 2012)
- 5 EMS regions with regional coordinators (durational employees)
- 26 sponsor hospitals providing medical direction
- 13 Coordinated Medical Emergency Direction Centers (CMEDs)
- 109 PSAPs
- Connecticut EMS Advisory Board (CEMSAB): 41 members
- Primary Service Area (PSA) system assigns exclusive geographic service areas
- Certificate of Need (CON) process and rate-setting authority
- Management Service Organizations (MSOs) licensed to provide personnel
- Notable demographic or socioeconomic factors cited: "Serves a relatively wealthy population, yet suffers financially" (Introduction, p.8). No specific socioeconomic data cited.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:An EMS plan dated 2006 was presented in draft form." (Regulation and Policy, p.9)
An updated trauma plan was submitted to DPH in 2007, but has not been released." (Trauma Systems, p.35)(b) Data points: A statewide EMS plan was drafted in 2006 pursuant to statutory requirements — still in draft form as of 2013. A trauma plan update was submitted to DPH in 2007 but not released. The original trauma plan was completed in 1995. (c) TAT characterization: The persistence of draft plans over 6–7 years is noted without explicit condemnation but implicitly documented as a gap. (d) Priority recommendations:
- OEMS should revise and update the 2006 statewide EMS plan as "a living document" for the next 5–7 years
- CEMSAB and OEMS should complete and publish the 2007 trauma system plan update
3B. Funding and Financial Sustainability
(a) Direct quotes:The OEMS is funded through a hodgepodge of different sources and has no direct funding line from the Department or the state legislature." (Regulation and Policy, p.9)
The office is understaffed, and two key positions found in most state EMS offices (Trauma Manager and Data Manager) are not present." (Regulation and Policy, p.9)
Fees obtained through licensure are not reinvested in the EMS system." (Regulation and Policy, p.10)
These funding inadequacies are potentially enough to adversely impact the long term sustainability of the EMS system as a whole." (Regulation and Policy, p.10)
There are no dedicated funds at the state level to support regulatory and system development opportunities." (Resource Management, p.13)
There is no funding for medical oversight within the system." (Medical Direction, p.32)(b) Data points:
- OEMS has no direct funding line from DPH or legislature
- Funded through "hodgepodge" of sources
- No Trauma Manager position; no Data Manager position; epidemiologist position vacant
- 5 regional coordinator positions are "durational employees" — 2-year funding commitment only
- Licensure fees not reinvested in EMS system
- For-profit services charged $200 PSA license fee; municipal/volunteer/nonprofit services not charged
- DMV assesses $20 vehicle inspection fee; OEMS assesses no fees for inspections
- No funding for medical oversight — sponsor hospitals provide without compensation
- No dedicated state funds for EMS system support
- Rate-setting authority exists; reimbursement rates for Medicaid/Medicare reported as insufficient
- Ambulance providers can only charge for services if patient is transported
- State Highway Safety grant funds used to purchase Toughbooks for ePCR distribution
- DPH should pursue dedicated cash funding source for EMS (examples: motor vehicle registration fees, moving traffic violation fees)
- Ensure all OEMS personnel positions are made permanent state-funded
- Secure required FTE support and permanent funding for trauma system
- Create and fill Trauma Manager, Data Manager, and epidemiologist positions
- Investigate funding mechanisms for medical oversight compensation
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:This pool of providers has remained consistent for the past several years." (Human Resources, p.17)
Concerns exist within the EMS community that the adoption of higher standards for clinical education over time may contribute to decreased volunteer personnel for rural and suburban agencies." (Human Resources, p.17)
One of the most significant shortcomings in the EMS workforce in Connecticut is the shortage of leadership/management training opportunities for current and future EMS system directors." (Human Resources, p.17)(b) Data points:
- Over 23,000 certified/licensed providers at all levels — consistent for several years
- ~700 providers certified as Advanced EMTs (level under review)
- 60-day certification turnaround time due to limited OEMS staffing
- Only 2 OEMS staff members for training oversight (one lead)
- No criminal background checks required for EMS certification
- No educational/examination requirements for paramedic re-licensure
- National Scope of Practice adopted as minimum; NREMT required for initial certification but not maintenance
- All paramedic programs expected to achieve CAAHEP accreditation
- Refresher examinations developed in-house — not educationally validated
3D. Essential Service Designation
Not documented in this report. The term "essential service" does not appear. EMS is described as a component of the "overall healthcare continuum" and "statewide health care system."3E. Regulatory Fragmentation
(a) Direct quotes:The Connecticut EMS system is an enigma. It is advanced and finely detailed in many areas, yet relatively undeveloped in others." (Introduction, p.8)
It serves a governmental system that is centered around 169 municipalities rather than counties or regions." (Introduction, p.8)
The practice of issuing primary service areas (PSAs) to multiple agencies for different aspects of EMS care within each of the 169 local jurisdictions is complex and can be seen as confusing at best." (Regulation and Policy, p.10)
The practices of rate setting, Certificate of Need requirements and issuance of PSARs are dated, and when combined are stifling to quality EMS provision." (Regulation and Policy, p.10)
Failure to actualize the full potential of the EMS regionalization concept is causing inefficiencies and added costs to the delivery of care, as well as blocking improvements to the quality of care provided." (Regulation and Policy, p.10)
Only 30% of EMS Medical Directors had any EMS training." (Medical Direction, p.33)(b) Data points:
- 169 municipalities — primary unit of EMS governance
- 5 EMS regions established but "barely utilized"
- Regional coordinators are durational employees (2-year funding)
- 26 sponsor hospitals providing medical direction — when surveyed about QA/QI, only 20 responded
- Only 2 of 5 regions have regional protocols
- PSA system assigns exclusive geographic service areas for different levels (first response, BLS, ALS) — "convoluted" and "not clearly understood by system participants"
- Certificate of Need required to add even a single vehicle within a PSA
- Legislative task force assigned to review PSA issues (report due February 2014)
- CEMSAB has 41 members — "unwieldy" with many appointed members not participating
- Regulations not updated for over 10 years; draft regulations circulating "for a multitude of years"
- EMS regions and State EMA regions are consistent
- No statewide implementation of CDC 2011 trauma triage guidelines (approved by CEMSAB but not implemented)
- No state credentialing for STEMI or stroke centers
- Only 1 region has QA/QI standards and goals
- Legislature should review and streamline PSA system; consider regional approach
- DPH should promulgate draft regulations "as soon as possible"
- Regulations should be reviewed annually with 120–180 day update process
- Restructure CEMSAB for efficiency; ensure active appointees
- Pursue regionalized system of emergency care for trauma, stroke, cardiac, and other time-critical conditions
3F. Data and Evaluation Systems
(a) Direct quotes:Although there has been a lack of significant progress in this area since the last assessment, the OEMS is commended for the work that it has been able to accomplish in the last year." (Evaluation, p.39)
The State has successfully uploaded their 2012 records, comprising over 500,000 ePCRS, to the National EMS Database. A great success indeed!" (Evaluation, p.39)
Currently, 95% of required agencies are uploading their data." (Evaluation, p.39)
Despite this requirement, only 19 hospitals provide data to the state trauma registry." (Evaluation, p.39) [out of 29 acute care hospitals]
It is unlikely that the state will be able to make any improvement in its ability to provide data to stakeholders, constituents, or legislators until these positions are filled." (Evaluation, p.40)
There appears to be no legislation or rule that specifically protects the databases from legal discovery although contributors have been unable to get any functional data out of the system." (Evaluation, p.40)(b) Data points:
- Over 500,000 ePCRs uploaded to National EMS Database in 2012
- 95% of required agencies uploading data
- 11 different ePCR programs in use statewide
- Data aggregator contracted with Digital Innovations
- Trauma registry: required by law for all acute care hospitals; only 19 of 29 submit data (13 trauma centers + 6 others)
- 2 non-designated hospitals submit to NTDB; at least 1 trauma center in TQIP
- No state registry or data collection for stroke, STEMI, or cardiac arrest
- No statewide data dictionary
- No EMS minimum data set
- No data returns to contributing hospitals from trauma registry
- No patient outcome data available at any level
- EMS epidemiologist position vacant; no Data Manager position; no Trauma Manager position
- One regional coordinator (durational employee) serving as data liaison
- No legislation protecting databases from discovery
- No protection for QA/QI activities at any level except possibly hospital-based "peer-review" standing meetings
- OEMS cannot provide legislature with required reports
- Toughbooks distributed to agencies using Highway Safety grant funds
- Fill epidemiologist position; create and fill Data Manager position
- Develop statewide EMS data dictionary and minimum data set
- Develop legislation protecting databases and QA/QI activities from discovery at all levels
- Create/provide QI toolkits for local use
- Ensure patient outcome data available to all levels of EMS system
- Develop and implement statewide performance improvement plan
3G. Trauma System Status
(a) Direct quotes:Connecticut was an early leader in state trauma system implementation." (Trauma Systems, p.35)
Since that time, progress has been slow for many reasons, including the fact that there is not a trauma-specific FTE within the Office of EMS." (Trauma Systems, p.35)
The original trauma system plan and trauma triage guideline are now outdated and obsolete, but have not yet been replaced." (Trauma Systems, p.35)
Although the current Connecticut trauma system has many of the necessary components and appears to function well, in reality there is no objective proof of this." (Trauma Systems, p.35)(b) Data points:
- Original trauma plan: 1995 (based on HRSA Model Trauma Care System Plan)
- Updated plan submitted 2007 — not released
- 13 designated trauma centers: 2 pediatric Level I, 2 adult Level I, 8 Level II, 1 Level III (all ACS verified)
- 16 acute care hospitals not designated — should be encouraged into inclusive system
- Regulation 19a-177 (1995) allows for Level IV — no state or ACS process to verify
- Trauma triage guidelines from 1995 regulation — outdated; 2011 CDC guidelines approved by CEMSAB but not implemented statewide
- No trauma-specific FTE in OEMS
- Trauma registry data submitted but not returned to hospitals
- No preventable mortality study conducted
- 1 accredited burn center (Bridgeport Hospital); three surrounding states provide additional burn support
- 2 Level I pediatric trauma centers (also full-service children's hospitals)
- No dedicated trauma system funding
- Create and hire State Trauma System Manager
- Create and hire State Data Manager for EMS and trauma
- Fill epidemiologist position (mentioned 3 times across report)
- Complete and publish updated trauma plan
- Implement 2011 CDC trauma triage guidelines statewide
- Develop Level IV trauma center designation process
- Perform and publish statewide preventable mortality study
- Provide annual trauma system report to stakeholders
3H. Medical Direction
(a) Direct quotes:The State EMS Medical Director is a contracted consultant who provides advice to the OEMS regarding issues but does not have any specific authority." (Medical Direction, p.32)
Only 30% of EMS Medical Directors had any EMS training." (Medical Direction, p.33)
As a result, sponsor hospitals are reluctant to have minimal regulatory standards for the provision of medical oversight and there is little accountability in the system regarding medical direction." (Medical Direction, p.32)
There is no funding for medical oversight within the system." (Medical Direction, p.32)(b) Data points:
- State EMS Medical Director: contracted consultant, no specific authority, not required by statute (appears in new draft regulations)
- Described as "engaged and well-respected"
- Leading New England regional protocol project
- 26 sponsor hospitals provide medical direction for agencies above EMT-Basic
- Only 30% of EMS Medical Directors had any EMS training
- No EMS-specific training required for medical directors (board certification in EM required)
- No funding for medical oversight
- No liability protections for sponsor hospitals or EMS Medical Directors
- No discovery protections for QA/QI at any level except possibly hospital peer-review meetings
- Regional EMS Medical Director role exists in regulation but limited to "representing" the region — no authority
- Only 2 of 5 regions have regional protocols
- Online Medical Control rarely utilized — systems are "standing order" driven
- No ongoing requirement for medical oversight of EMD
- When 26 sponsor hospitals surveyed about QA/QI, only 20 responded
- Ensure State EMS Medical Director and regional medical directors have sufficient authority for statewide protocols, guidelines, and QI
- Require ALL levels of EMS provider and EMD providers to have indirect medical oversight
- Implement statewide protocol guidelines "as soon as possible"
- Pursue legislation for discovery protection and liability protection for medical directors
- Investigate funding mechanisms for medical oversight compensation
- Establish initial and ongoing training requirements for medical directors
- Require pediatric specialist input for all protocol development
3I. Communications and Infrastructure
(a) Direct quotes:Connecticut was one of the first states to implement a statewide 9-1-1 system." (Communications, p.27)
By the end of February 2014, Connecticut will have a fully interoperable medical communications system with standard operating frequencies." (Communications, p.27)(b) Data points:
- 109 PSAPs statewide
- 13 CMEDs — varying volume; some have no hospitals in their region; consolidation under discussion
- Enhanced 9-1-1 statewide
- All ambulances and hospitals equipped with UHF radios; hospitals also have satellite phones
- VHF MEDNET radios purchased with Public Health Emergency Preparedness funds
- DPH migrating to state police communications backbone with statewide DPH talk groups
- EMD required by statute since 2000; training/certification under Office of Statewide Telecommunications (OSET)
- No OEMS certification or recertification criteria for EMD
- No reporting criteria for communities to maintain certified dispatchers
- No routine EMD QI process
- No data to assess dispatcher impact on patient outcomes
- EMS communications plan exists and has been revised
- Complete CMED utilization review for appropriate distribution
- Establish regulatory standard for medical direction of dispatch centers using EMD
- Incorporate EMD into local/regional/state QI processes
- Automate dispatch and auto-populate ePCR from CAD data
3J. Preparedness
(a) Direct quotes:Connecticut has experienced an unusually high number of real-world events in recent years, and these events have tested and improved the coordination of EMS emergency response." (Preparedness, p.41)(b) Data points:
- Recent real-world events: power plant explosion, two hurricanes, a train crash, and a multi-fatality school shooting (Sandy Hook, December 2012 — not named but described as "multi-fatality school shooting")
- Long-term care facility evacuations also experienced
- OEMS role in State Health Operations Center and State EOC well understood
- EMAC participation and NIMS compliance evident
- Pandemic influenza plans include EMS considerations
- Mass gathering regulations developed (local compliance reported as limited)
- EMS Crisis Standards of Care under development
- Altered dispatch protocols executed during past events
- 169 municipalities each have Emergency Management Agency — consistent with EMS regions
- Smaller agencies and private providers may need additional preparedness focus
- Identify and close preparedness gaps in smaller agencies (PPE, training, planning, exercises)
- DPH should be more involved in OEMS/Public Health Preparedness collaboration
- Develop written statewide EMS workforce protection plan
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
This is a reassessment of the 2000 reassessment (13-year interval).
The majority of recommendations contained within the 2000 state review report have been successfully implemented." (Human Resources, p.17 — specifically regarding education)
Since the last NHTSA system review report in 2000, the Connecticut EMS and trauma system has continued to evolve in a variety of ways." (Resource Management, p.12)Key progress documented:
- National Scope of Practice adopted as minimum
- NREMT required for initial certification
- Paramedic program accreditation through CoAEMSP mandated
- Electronic patient care reporting implemented statewide (95% compliance, 500,000+ ePCRs to NEMSIS)
- New OEMS Director selected 2012 — "robust level of energy, dedication and innovation"
- Administrative rules (OHS 110) updated
- HeartSafe program implemented with AHA collaboration
- Statewide interoperability nearly complete
- Real-world disaster response tested repeatedly
- State EMS plan still in draft (2006 draft; originally required by statute)
- Trauma plan not released (2007 update submitted to DPH but unreleased)
- Trauma triage guidelines still outdated (1995 regulation)
- PSA system still convoluted — legislative task force now reviewing
- Regulations not updated for over 10 years; draft circulating "a multitude of years"
- No Trauma Manager, Data Manager, or epidemiologist
- No discovery protection for QA/QI
- Rate-setting and CON practices still "dated"
- Driver training still not required for ambulance operators
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall characterization:The Connecticut EMS system is an enigma. It is advanced and finely detailed in many areas, yet relatively undeveloped in others." (Introduction, p.8)
It is a system that has been tried by real life events and passed the test each time." (Introduction, p.8)
The key to the future lies in mastering basic, yet key EMS system principles, letting go of practices that no longer serve the patient's best interests... even when they seem to still work." (Introduction, p.8)Structural barriers identified:
- 169-municipality governance structure with no county-level EMS infrastructure
- PSA/CON/rate-setting triad described as "dated" and "stifling"
- Regionalization concept "barely utilized"
- Draft regulations circulating for years; EMS plan in draft since 2006
- No direct funding line; licensure fees not reinvested
- Sponsor hospital medical direction model without funding, accountability, or training requirements
- No discovery protections for QA/QI at any level
The report frames EMS within the healthcare continuum: "a noticeable interest in integration of EMS care into the overall healthcare continuum at the Department" (Regulation and Policy). The PSA/CON/rate-setting model reflects a public utility regulatory approach.
Federal funding mechanisms:- Highway safety funds referenced as original TAT mechanism
- State Highway Safety Office supported assessment
- State Highway Safety grant funds used for Toughbook purchases
- HRSA Model Trauma Care System Plan referenced
- Public Health Emergency Preparedness program funds for MEDNET radios
- Traffic Records Coordinating Committee partnership for data linkage grant
- Successful NEMSIS upload of 500,000+ ePCRs — "a great success indeed!"
- 95% agency compliance with data upload
- Strong disaster response validated by real-world events
- New OEMS Director (2012) bringing energy and innovation
- HeartSafe program
- Early 9-1-1 adoption; near-complete interoperability
- Active EMSC program
- Two Level I pediatric trauma centers
- New England regional protocol project under development
- CMED system connecting ambulances to all hospitals
- Committed OEMS staff and DPH leadership support
- "Hodgepodge" funding with no dedicated source
- OEMS understaffed; Trauma Manager, Data Manager, epidemiologist all absent
- State EMS plan in draft since 2006; trauma plan unreleased since 2007
- Regulations not updated for over 10 years
- PSA system "confusing" and "stifling"
- Only 30% of EMS Medical Directors have EMS training
- No funding or accountability for medical oversight
- No discovery protections for QA/QI
- Trauma registry data not returned to hospitals; no system performance assessment
- 16 of 29 acute care hospitals not in trauma system
- No data collection for stroke, STEMI, or cardiac arrest
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
"An Enigma" — Advanced Yet Undeveloped
The TAT's characterization of Connecticut's EMS system as "an enigma" — "advanced and finely detailed in many areas, yet relatively undeveloped in others" — captures a paradox. The state has early-adopter achievements (statewide 9-1-1, trauma plan in 1995, NEMSIS compliance) alongside basic gaps (regulations not updated for a decade, trauma plan unreleased since 2007, no data returned to hospitals).
169-Municipality Governance as Root Structural Constraint
Connecticut's governance centered on 169 municipalities rather than counties or regions is the root structural finding. Counties have no EMS infrastructure. This creates a PSA system where multiple agencies serve different EMS levels within each municipality, producing what the TAT called "complex and confusing at best."
PSA/CON/Rate-Setting Triad — Public Utility Model
Connecticut regulates EMS through a unique combination of Primary Service Areas, Certificate of Need, and rate-setting authority that the TAT characterized as "dated" and "stifling to quality EMS provision." This public utility regulatory model, where even adding a vehicle within an existing PSA requires a CON application, is unusual across the corpus.
Only 30% of EMS Medical Directors Trained
The finding that only 30% of EMS Medical Directors had any EMS training, despite board certification in emergency medicine being required, is one of the most striking medical direction findings in the corpus. Combined with no funding, no accountability, and no discovery protections, this creates what the TAT described as "little accountability in the system regarding medical direction."
Sandy Hook Response (Implicit)
The report references "a multi-fatality school shooting" among recent real-world events — a reference to the Sandy Hook Elementary School shooting of December 14, 2012, which occurred approximately 7 months before the TAT visit. The report does not name the event but lists it among events that "tested and improved the coordination of EMS emergency response."
Sponsor Hospital Model Without Funding or Accountability
The medical direction model relies on 26 sponsor hospitals providing oversight without compensation, training requirements, or accountability mechanisms. When surveyed about QA/QI, only 20 of 26 responded. This is a structural finding where the medical oversight infrastructure is nominally present but functionally unsupported.
500,000 ePCRs to NEMSIS but No Ability to Use the Data
Connecticut successfully uploaded over 500,000 ePCRs to the National EMS Database — praised as "a great success indeed!" — yet lacks the staff to analyze the data, provide reports to the legislature as required by law, or return any data to contributing agencies or hospitals. The data aggregator collects 11 different ePCR formats but there is no statewide data dictionary or minimum data set.
Durational Employees as Regional Infrastructure
The 5 regional coordinators — described as the "key link between the DPH and the 169+ municipalities" — are classified as durational state employees with only 2-year funding commitments. The TAT stated this "severely undermines the concept of regionalization of healthcare and the authority of OEMS."
Draft Regulations Circulating "A Multitude of Years"
Draft regulations have been circulating for an unspecified but apparently lengthy period. The TAT recommended promulgation "as soon as possible" with a future annual review cycle of 120–180 days — implicitly characterizing the current pace as unacceptable.
Analysis produced using standardized NHTSA State EMS Assessment extraction framework. All quotes are from the Connecticut 2013 Reassessment report. No editorial synthesis applied.
Florida
Full Analysis
Florida 2013 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of Florida
- Report type: Reassessment
- Date of site visit: November 12–14, 2013
- Year of publication: 2013
- Prior assessment year: 1993
"The last NHTSA EMS assessment was conducted in 1993."
- TAT members:
- Theodore R. Delbridge, MD, MPH, FACEP
- Stephen Flaherty, MD, FACS
- D. Randy Kuykendall, MLS
- Drexdal Pratt, CPM
- Jolene R. Whitney, MPA
- NHTSA facilitator: Susan McHenry, MS
- Executive Support: Janice D. Simmons, BFA
- Number of presenters/briefings: Over 20 presenters
- Requesting agency: Florida Department of Health, Office of Emergency Medical Services Sections; initiated at recommendation of the ACS/COT Trauma Systems Consultation Report (February 2013)
SECTION 2: STATE CONTEXT
- Population (as cited in report): Nearly 19 million residents; approximately 91 million visitors annually
- Geographic characteristics:
"The land mass is one of the largest in the country"
"1,350 miles of coastline are the longest coastline of any of the contiguous United States"
"there are large tracts of low-density land with difficult terrain features, notably swamp"
Twenty metropolitan statistical areas in the state. Hurricane vulnerability highlighted. The report characterizes Florida as having both high-density urban areas and challenging rural terrain.
- Number of counties/jurisdictions: 67 counties
- EMS system overview:
- Lead agency: Florida Department of Health (DOH), EMS Section within the Bureau of Emergency Medical Oversight, under the Division of Emergency Preparedness and Community Support, under the Florida Surgeon General
- "Home rule" state — county governments as cornerstone of EMS provision
- Counties issue Certificate of Public Convenience and Necessity (COPCN) for EMS agencies
- No structured regional system of planning or care
- State EMS Advisory Council with EMS for Children Committee, Data Committee, Disaster Committee, PIER committee
- Emergency Medical Review Committee (EMRC)
- 274 licensed EMS agencies (173 ALS transport, 59 ALS non-transport, 8 BLS transport, 34 air ambulance)
- 66,244 certified EMS providers
- ~4,231 permitted ground vehicles; 125 permitted aircraft
- 179 EMS medical directors for 274 agencies
- 57 paramedic training programs (39 nationally accredited or pursuing)
- 19 trauma service areas (TSAs) with sporadically located trauma agencies
- State EMS Medical Director: ~40% FTE, contract through FAEMSMD, not in statute
- EMSTARS data system: ~75% of 3.6 million annual encounters captured (voluntary)
- 2 ambulance inspectors for 4,000+ vehicles
- EMS education oversight: 1 staff member
- Florida Association of EMS Medical Directors (FAEMSMD): less than 50% of medical directors actively participate
- Notable demographic or socioeconomic factors cited:
"4th most populous state of the union"
"nearly 91 million visitors a year"
Hurricane vulnerability explicitly noted. The 2013 ACS/COT consultation was prompted by "discord and program uncertainties" resulting in "unwanted local, regional and national spotlights."
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:
"There is no structured regional system of planning or care in the EMS system."
"On a day-to-day basis, the trauma system functions as a loose aggregation of trauma centers, with little cooperation between trauma centers and almost no central coordination of EMS or trauma center activity" (quoted from ACS/COT 2013 report)
"The reports and documents submitted in the course of this NHTSA technical assistance visit suggest that this finding extends broadly throughout the EMS system."
"there are informal regional affiliations among some provider agencies in various parts of the state"
(b) Specific data points:
- 67 counties each responsible for EMS provision under home rule
- 19 trauma service areas (TSAs) with sporadically located trauma agencies
- Strategic plan updated every 5 years through EMS Advisory Council
- No formalized regional EMS advisory councils
- Disaster planning described as "best practice across the nation" (Ambulance Deployment Guideline, Air Medical Disaster Response Plan)
(c) Report characterization: The TAT extends the ACS/COT finding of "loose aggregation" to the entire EMS system. No regional planning structure exists despite 67 county governments operating independently.
(d) Priority recommendation status: Yes. Establishing formalized regional systems of planning and care is recommended.
3B. Funding and Financial Sustainability
(a) Direct quotes:
"Currently, the EMS Section has only two inspectors for over 4,000 permitted ambulances in the state."
"less than 30% of requested funds have been awarded"
"the resources available to the EMS Section to accomplish its regulatory responsibilities are significantly limited"
"There appears to be insufficient personnel resources assigned to a number of critical resource functions"
(b) Specific data points:
- EMS Trust Fund: annually, less than 30% of local grant requests funded
- Ambulance inspectors: 2 for 4,000+ vehicles
- EMS education oversight: 1 staff member for 57 paramedic programs and 66,244 providers
- State EMS Medical Director: ~40% FTE through FAEMSMD contract
- Federal preparedness funding (PHEP + ASPR): $145 million over 3 years (state total, not EMS-specific)
- Florida Interoperability Network (FIN): declined from 240 sites to 160 sites due to funding
- 911 revenue threatened by pay-per-use wireless phones (no zip code, no fee) and landline abandonment
- No ambulance inspection schedule required in state law
(c) Report characterization: The TAT repeatedly identifies understaffing as a critical barrier. The 2:4,000 inspector-to-vehicle ratio and 1-person education oversight are the most extreme staffing ratios in the corpus.
(d) Priority recommendation status: Yes. Increasing EMS Trust Fund revenue, adequate inspection staffing, and additional education staff are recommended.
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:
"With 66,244 certified EMS providers, the workforce appears to be sufficient, although gaps in some rural communities may exist."
"Although woefully understaffed, the EMS program has managed to support an EMS education system that may provide sufficient workforce resources"
"Particularly in rural areas, willing potential EMS medical directors may be difficult to identify."
(b) Specific data points:
- 66,244 certified EMS providers
- 57 paramedic programs; 39 nationally accredited or pursuing
- Florida does not recognize national Paramedic certification (state exam required) — "one of only a few states"
- No EMR or AEMT certification established (EMS Section concluded unnecessary)
- No national accreditation requirement for paramedic programs
- State Paramedic exam not nationally validated
- Recertification: minimum 2 hours pediatric CE required per cycle
- No statewide workforce health and safety initiatives
(c) Report characterization: The TAT describes the workforce as "appears to be sufficient" — the most positive workforce assessment in the corpus. However, the state's rejection of national Paramedic certification is identified as a barrier to reciprocity and recruitment, and "woefully understaffed" describes the state-level oversight capacity.
(d) Priority recommendation status: Yes. National certification, national accreditation, additional education staff, and workforce health assessment are recommended.
3D. Essential Service Designation
(a) Direct quotes:
"Statute requires that EMS services be provided in all counties"
(b) Specific data points:
- Florida statute requires counties to ensure EMS provision through the COPCN process
(c) Report characterization: Florida has a statutory requirement for EMS provision in all counties, functionally equivalent to essential service designation through the COPCN mechanism. The TAT does not identify this as a gap.
(d) Priority recommendation status: Not documented as a recommendation — the statutory requirement appears to satisfy this need.
3E. Regulatory Fragmentation
(a) Direct quotes:
"Florida is a 'home rule' state where the authority of the 67 county governments is the cornerstone of how EMS services are provided"
"administrative inertia over the past 10-15 years resulted in non-compliance with statutory mandates that directly led to a contentious atmosphere mired in legal wrangling over trauma center designation"
"Specialty Care services are now being offered... Current law or rule does not define specialty vehicles or address equipment and staffing needs for this type of service"
"within the past two years there has been discord and program uncertainties that has resulted in unwanted local, regional and national spotlights"
(b) Specific data points:
- 67 county governments with COPCN authority
- Hospital licensure: Agency for Health Care Administration (AHCA) — separate from DOH
- EMS Section: under DOH
- State EMS Medical Director: not in statute, no statutory authority
- No statewide baseline protocols
- No destination protocols for STEMI, ACS, or pediatrics (only trauma and stroke)
- Specialty care transport: unregulated
- Some agencies don't recognize hospital diversion status
- No time requirement for ambulance inspections in state law
- Equipment list not updated in over a decade
(c) Report characterization: The TAT describes the recent history as "discord," "program uncertainties," "unwanted spotlights," "administrative inertia," "non-compliance," and "legal wrangling." This is the most negative recent-history characterization in the corpus. The 2013 ACS/COT consultation was followed immediately by this NHTSA reassessment, suggesting a system in active remediation.
(d) Priority recommendation status: Yes. Multiple recommendations on codifying the medical director position, statewide protocols, specialty care regulation, and inspection requirements.
3F. Data and Evaluation Systems
(a) Direct quotes:
"participation is voluntary with only approximately 75% of the 3.6 million annual patient encounters reported in the system"
"Some, collectively providing care to approximately 25% of the state's EMS patients, submit aggregate data on a monthly basis."
"there are notable exclusions including most of Dade County"
"On a statewide basis there is little ability to evaluate the effectiveness of the EMS system in terms of improving outcomes."
"EMSTARS currently contains data for millions of EMS encounters. However, the abilities to query the database and provide meaningful feedback to EMS agencies are lagging."
(b) Specific data points:
- EMSTARS: ~75% of 3.6 million annual encounters (voluntary participation)
- ~25% of patients: aggregate monthly summary data only
- Dade County: mostly excluded
- Next Generation Trauma Registry (NGTR): test mode, go-live January 1, 2014
- Transitioning to NEMSIS v3 (not yet implemented)
- Data confidentiality concerns identified as barrier to participation
- No statutory protection for EMS database from legal discovery (legislative recommendation)
- EMRC conducts high-level system evaluations using EMSTARS
- Response time intervals and capnometry documentation evaluated
- GIS mapping of call data conducted
- Limited query/feedback capability
- No ability to evaluate outcomes statewide
(c) Report characterization: The TAT structures the evaluation discussion around three tiers — structures, processes, outcomes — and concludes Florida has limited structural awareness, some process measurement capability, and "little ability" to evaluate outcomes. This is a sophisticated analytical framework not used in other reports.
(d) Priority recommendation status: Yes. Mandatory EMSTARS participation, legislative data protection, agency-specific feedback/report cards, data linkage, and adequate funding/staff are recommended.
3G. Trauma System Status
(a) Direct quotes:
"Florida has demonstrated a clear commitment to the care of the injured patient as far back as the early 1980s, resulting in a long history of trauma leadership at the national level."
"administrative inertia over the past 10-15 years resulted in non-compliance with statutory mandates that directly led to a contentious atmosphere mired in legal wrangling over trauma center designation"
(b) Specific data points:
- 19 trauma service areas (TSAs)
- Trauma agencies: "sporadically located"
- ACS/COT consultation: February 2013 (prompted this NHTSA reassessment)
- Post-ACS hires: Administrative Program Director (April 2013), QI Coordinator (July 2013), Medical Director (September 2013)
- NGTR in test mode for January 2014 go-live
- Statutory Revision Ad Hoc Committee: began October 2013
- Six specialty designation areas through AHCA (Burn, Primary Stroke, Comprehensive Stroke, Cardiac Catheterization, Level 1/2 Cardiovascular)
- Level I and Level II trauma center designation in statute
- Not all acute care facilities participate in trauma system
- Not all facilities submit data to state registry
(c) Report characterization: The TAT acknowledges Florida's historical national trauma leadership while documenting 10-15 years of "administrative inertia" and "legal wrangling." The rapid response to the ACS/COT report (three hires and multiple initiatives within 9 months) is noted positively.
(d) Priority recommendation status: Yes. Mandatory inclusive system participation, facility designation at appropriate level, and mandatory data submission are recommended — endorsing the ACS/COT recommendations.
3H. Medical Direction
(a) Direct quotes:
"Medical direction of Florida's EMS system is among its strengths. At the same time it is one of its most prominent sources of potential undesired variation."
"There are no statewide EMS protocols, nor is there specific direction as to what local protocols are required"
"Beyond having a Florida medical license, there are no specific required qualifications for EMS medical directors."
"The State EMS Medical Director is not, however, mentioned in statute. Thus, it is possible that a future leadership change or other pressures... could lead to position elimination"
"less than 50% of EMS medical directors actively participate" (in FAEMSMD)
(b) Specific data points:
- 179 EMS medical directors for 274 agencies
- State EMS Medical Director: ~40% FTE, contract through FAEMSMD, not in statute
- No qualifications beyond medical license
- No statewide protocols — no baseline or floor for care
- No destination protocols for STEMI, ACS, or pediatrics
- No mechanism to validate necessity of protocol variations
- No specific plan to cultivate medical directors
- No statewide medical direction for dispatch
- State EMS Medical Director selected by FAEMSMD vote — no statutory selection process
(c) Report characterization: The TAT's characterization of medical direction as simultaneously a strength and "most prominent source of potential undesired variation" is among the most nuanced in the corpus. The 40% FTE position with no statutory authority, no statutory existence, and no qualifications beyond licensure represents substantial vulnerability.
(d) Priority recommendation status: Yes. Codifying the State EMS Medical Director position, establishing medical director qualifications, developing statewide baseline protocols, and evaluating protocol variation are recommended.
3I. Communications and Infrastructure
(a) Direct quotes:
"Florida is to be commended for the development of a comprehensive EMS communications plan"
"There are no requirements for PSAPs to utilize priority dispatch systems when taking calls from the public."
"It is not known how many PSAPs are utilizing medical protocol dispatch systems."
"there appears to be little state or local medical direction oversight for EMS dispatchers"
(b) Specific data points:
- All counties: operational Enhanced 911
- 911 Board coordinates statewide development
- Public Safety Telecommunicator (PST) training: 232 hours; certification mandatory since 2010; over 8,000 certified
- PST certified for 2-year periods with 20 hours CME
- No priority dispatch requirement
- Unknown number of PSAPs with medical dispatch systems
- Florida Interoperability Network (FIN): declined from 240 sites to 160 sites
- FIN: proprietary technology; future should be P25 compliant
- MED-8 statewide scene coordination channel
- 700 MHz interoperability and 800 MHz mutual aid channels
- No auto-population of dispatch data into EMSTARS
(c) Report characterization: Communications infrastructure is praised (comprehensive plan, mandatory PST certification) but priority dispatch utilization is unknown and medical direction oversight is absent. The FIN decline from 240 to 160 sites is characterized as a sustainability concern.
(d) Priority recommendation status: Yes. Assessment of medical dispatch utilization, CAD-to-ePCR auto-population, FIN sustainability, and NG911 funding are recommended.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (1993 Assessment)
A 20-year gap between the 1993 assessment and 2013 reassessment. The report does not include formal "Progress on Prior Recommendations" sections. A single reference:
"Many of the recommendations of the 1993 assessment have been implemented and have obviously contributed to the many successes of the system to date."
No systematic accounting of 1993 recommendation completion status is provided.
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall System Characterization
"The EMS Section in the Bureau of Emergency Medical Oversight under the Department of Health leads and manages a mature Emergency Medical Services system that historically is well respected nationally."
"within the past two years there has been discord and program uncertainties that has resulted in unwanted local, regional and national spotlights"
The introduction uses the Fountain of Youth metaphor:
"the Florida EMS System seeks to renew itself in the waters of the mythical Fountain to help find vigor and vitality"
This is the only report in the corpus framing the assessment as a renewal following a period of system dysfunction.
Structural Barriers Identified
1. Home rule / 67-county fragmentation — no regional structure, each county operating independently
2. Recent system discord — "administrative inertia," "legal wrangling," "unwanted spotlights"
3. Extreme understaffing — 2 inspectors for 4,000+ vehicles; 1 education staffer for 57 programs
4. No statewide protocols — no baseline care floor across 274 agencies
5. State EMS Medical Director not in statute — 40% FTE, no authority, eliminable
6. EMSTARS voluntary — 25% of patients get only aggregate data; Dade County excluded
7. National certification rejected for Paramedics — reciprocity barrier
8. No data confidentiality protection in statute — barrier to participation
9. Declining interoperability infrastructure — FIN shrinking
10. No destination protocols for STEMI, ACS, pediatrics
11. Specialty care transport unregulated
12. Equipment list not updated in 10+ years
Greatest Strengths (as identified by the TAT)
- Historical national trauma leadership since 1980s
- Disaster preparedness: "best practice across the nation"
- Comprehensive EMS communications plan
- Mandatory PST certification (8,000+ certified)
- EMSC program: national pediatric readiness score among highest
- Robust injury prevention program
- Rapid response to ACS/COT recommendations (3 hires in 9 months)
- 91 million visitor management experience
- Extensive strategic planning activities
- EMS-C Advisory Committee, Safe Kids coalitions (41 counties)
- EMresource/HavBed implementation
Most Critical Challenges
- System "discord" requiring external intervention (ACS/COT + NHTSA)
- 2:4,000+ inspector-to-vehicle ratio
- No statewide protocols
- State EMS Medical Director vulnerable to elimination
- EMSTARS voluntary with major gaps
- No regional coordination structure
- No outcome evaluation capability statewide
- National certification rejection isolating Florida's Paramedic workforce
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
System in Active Remediation
Florida is the only state in the corpus where the assessment was explicitly triggered by a prior crisis. The ACS/COT consultation in February 2013 recommended the NHTSA reassessment, and the TAT notes "discord and program uncertainties" leading to "unwanted local, regional and national spotlights." The rapid post-ACS response (3 hires, multiple initiatives) suggests active institutional remediation during the assessment period itself.
Most Extreme Staffing Ratios in Corpus
2 ambulance inspectors for 4,231 vehicles and 1 education oversight staff for 57 programs and 66,244 providers are the most extreme regulatory staffing ratios documented in any report analyzed. Iowa's 4 coordinators for 931 programs is the nearest comparison.
"Loose Aggregation" — ACS/COT Language Adopted
The TAT endorses the ACS/COT characterization of the trauma system as a "loose aggregation... with little cooperation between trauma centers and almost no central coordination" and explicitly extends it to the entire EMS system.
National Certification Rejection
Florida's refusal to recognize national Paramedic certification — using a state exam instead — is identified as both a reciprocity barrier and a workforce recruitment impediment. The TAT frames this as inconsistent with the EMS Education Agenda for the Future.
Largest System in Corpus
With 66,244 providers, 274 agencies, 4,231 vehicles, 19 million residents, and 91 million annual visitors, Florida is by far the largest system in the corpus. The scale creates unique challenges — a 2:4,000 inspector ratio that would be extreme anywhere is catastrophic for a system this large.
"Fountain of Youth" Framing
The introduction's Fountain of Youth metaphor — seeking renewal — is unique in the corpus as an acknowledgment of institutional aging and dysfunction requiring rejuvenation.
Structures/Processes/Outcomes Framework
The TAT's three-tier evaluation framework (structures, processes, outcomes) in the Evaluation section is the most analytically sophisticated evaluation discussion in the corpus. Most other reports simply note data gaps; Florida's TAT systematically categorizes what can and cannot be measured.
FAEMSMD Participation
Less than 50% of medical directors actively participating in the state medical directors association, despite it being the contractual vehicle for state medical direction, highlights a structural paradox: the body providing state-level medical oversight represents a minority of practicing medical directors.
911 Revenue Threat
The identification of pay-per-use wireless phones (no zip code, no 911 fee) as a funding threat is unique to this report and reflects a 2013-era concern about telecommunications revenue models that may have broader implications.
Home Rule Consistency
Florida is the third "home rule" state in the corpus (after Georgia and Idaho's similar "less government" culture). The TAT's recommendations for regionalization follow the same pattern: home rule creates fragmentation, TATs recommend formalized regional structures as a remedy.
Analysis completed per standardized NHTSA State EMS Assessment framework. No synthesis or editorial interpretation has been applied. Findings are extracted as documented in the report.
Georgia
Greatest Strengths
- OEMST positioned within Department of Public Health — "most appropriate home"
- Collegial culture of collaboration among EMS stakeholders
- Robust GEMSIS data system with Biospatial — "laudatory," "hidden gem"
- **96%** of stroke admissions captured in registry
- State EMS Medical Director recently hired
Most Critical Challenges
- Workforce shortages at all levels — "a serious problem without an easy solution"
- Home rule culture impeding clinical standardization
- OEMST budget insufficient; dependent on time-limited grants
- Declining GTC allocation to OEMST
- Closure of Level I trauma center during assessment — "fragility of the system"
Full Analysis
Georgia 2022 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of Georgia
- Report type: Reassessment
- Date of site visit: August 29 – September 1, 2022
- Year of publication: 2022
- Prior assessment year: 1995
- TAT members:
- Curtis Sandy, MD, FACEP, FAEMS
- Sabina Braithwaite, MD, MPH, FACEP, FAEMS
- Kyle Thornton, EMT-P, M.S.
- Alisa Habeeb Williams, NRP, B.S.
- NHTSA facilitator: Dave Bryson
- Executive Support: Susan Wiczalkowski
- Number of presenters/briefings: Not specified by count. The report states:
The TAT thanks all of the presenters for being candid and open regarding the status of EMS in Georgia and for their extraordinary efforts and well-prepared presentations.
Many of these individuals traveled considerable distance to participate.
- Requesting agency: Governor's Office of Highway Safety (GOHS) in collaboration with the Department of Public Health's Office of EMS and Trauma (OEMST)
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not explicitly stated as a specific figure. The report notes "Georgia is seeing significant population growth."
- Geographic characteristics: The report references "vastly diverse areas" and describes Georgia as having large rural regions with gaps in hospital resources. Of 159 counties, 54 are without a hospital. The report references bordering states for patient transport and identifies geographic barriers to specialty care access. The "southern" and "northwest quadrant" are specifically referenced as underserved areas.
- Number of counties/jurisdictions: 159 counties
- EMS system overview:
- The General Assembly found:
he furnishing of emergency medical services is a matter of substantial importance to the people of this State" (Code § 31-11-1)
- 10 EMS Regions, each with a Regional EMS Director, Regional EMS Training Coordinator, and Regional Emergency Medical Services Advisory Council (REMSAC)
- Advised by two groups: Emergency Medical Services Advisory Council (EMSAC) and Emergency Medical Services Medical Directors Advisory Council (EMSMDAC)
- Separate entity: Georgia Trauma Commission (GTC), created in 2007, appointed by Governor, Lt. Governor, and Speaker of the House
- 289 ground ambulance agencies, 7 air ambulance agencies, 7 neonatal ambulance agencies
- 2,365 ground ambulances, 48 air ambulances, 13 neonatal ambulances
- Over 1,000 licensed non-transporting EMS vehicles
- ~24,951 licensed EMS practitioners
- Notable demographic or socioeconomic factors cited: Significant population growth referenced but no specific socioeconomic data cited in the report.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:The State is organized into 10 EMS regions. Those regions are divided into zones with designated emergency ambulance services.
a resource and needs assessment evaluating the availability and geographic distribution of EMS personnel and physical resources is important to ensure a rapid and appropriate response... Such objective assessment (and reassessment) must be a high priority.
The report references a 2020 Strategic Plan and a prior 2009 ACS report as existing planning documents.
(b) Specific data points:- 10 EMS Regions
- Zoning system assigns 911 ambulance coverage; some zones have multiple providers
- REMSAC responsible for developing and implementing regional ambulance zoning plans
3B. Funding and Financial Sustainability
(a) Direct quotes:The OEMST has an annual budget of approximately $4.9 million. This budget includes time-limited grant funds and other outside revenue that may not be sustainable to support current and future needs of the EMS system.
Since 2019, the allocation has consistently decreased below the full 3% allowed by the Assembly. This decrease in funding has jeopardized three positions essential to the OEMST's statutory role in regulatory oversight of the trauma system and integration with other specialty systems of care.
Pandemic response workforce grant funding has allowed for the hiring of five OEMST positions that are now critical to the OEMST operation. The loss of these positions would potentially slow or even reverse progress made to meet the needs of the system during and after the COVID pandemic.
heir current staffing and budget levels are insufficient to accomplish all statutory, regulatory, and organizational mandates
The fiscal resources that support these activities are inadequate to meet system needs and expectations.
Outside the urban areas, medical directors are almost uniformly unpaid.(b) Specific data points:
- OEMST annual budget: ~$4.9 million (includes time-limited grants)
- GTC provides up to 3% of legislative allocation to OEMST; allocation has decreased below 3% since 2019 (fell to ~2.1%)
- 5 OEMST positions funded by pandemic grants — at risk of loss
- 3 OEMST positions jeopardized by GTC funding decrease
- GTC funded by "super-speeder" ticket fines and a percentage of a fireworks tax
- Office of Rural Health: over $13 million in grant funding over 10 years (mostly to hospitals)
- Air ambulance subsidy (northwest quadrant): $600,000 annual (State Office of Rural Health)
- No stroke coordinator funded at OEMST
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:Many presenters referenced staffing shortages throughout the State at all levels.
This is a complicated matter that has elements of numbers of personnel, whether those personnel are working within the EMS system, how many jobs people hold, etc. These workforce issues should be further evaluated.
This lack of personnel is a serious problem without an easy solution.
Part of the issue may be workforce limitations where a local EMS agency does not want to send its only ambulance and crew on an extended transport leaving the local service area uncovered.(b) Specific data points:
- ~24,951 licensed practitioners
- ~39% at EMT-Intermediate/AEMT level
- ~36% at Paramedic level
- The paramedic percentage is characterized as "astounding...easily eclipsing most States"
- EMS education programs offered to high school students in the public school system
3D. Essential Service Designation
(a) Direct quotes:he furnishing of emergency medical services is a matter of substantial importance to the people of this State" (Code § 31-11-1)(b) Specific data points:
- The Georgia General Assembly has codified EMS as a matter of "substantial importance" in State Code
- The zoning system assigns 911 ambulance coverage responsibilities
3E. Regulatory Fragmentation
(a) Direct quotes:here are gaps in this regulatory authority that need to be addressed. In recent years, a demand for EMS personnel and agencies providing EMS coverage for specific commercial and other atypical needs has resulted in a largely unregulated portion of the EMS industry.
he benefit of the public welfare necessitates adding air ambulance regulation to include fixed wing aircraft and crews that are otherwise unregulated
The regulatory, oversight, and funding structure of each of these specialty systems of care is disparate and could lead to confusion and inefficiencies in the system.
Georgia OEMST regulates trauma care. The GTC funds trauma care. Improved alignment in the mission and the role of these two groups is critical to streamline development and regional implementation of the trauma program.
There is a lack of centralized coordination of EMS and trauma assets at the State level.
here are first response agencies who are providing limited medical care that are neither licensed nor have a medical director
Georgia is a 'home rule' State, and there is a perceived resistance to mandates of any sort that could supersede local authority.(b) Specific data points:
- 10 EMS Regions with Regional Directors reporting to OEMST
- Specialty systems of care each have disparate regulatory, oversight, and funding structures
- OEMST regulates trauma; GTC funds trauma — separate entities
- Fixed wing air ambulance: unregulated
- Special event EMS, movie production EMS, search and rescue EMS, mass gathering EMS: largely unregulated
- Some first response agencies operating without licensure or medical directors
3F. Data and Evaluation Systems
(a) Direct quotes:Data is being captured Statewide on a National EMS Information System (NEMSIS) compliant system as well as a trauma registry. It is exciting to see the State moving toward turning their data into information that can be used both to inform the public and to guide decision making.
The work OEMST has done by providing a current, NEMSIS-compliant ePCR platform (GEMSIS), educating providers and agencies on appropriate use, together with effective data collection and validation is laudatory.
Specialized insights and data visualizations facilitated by use of GEMSIS data through Biospatial have the potential to be invaluable at both the State and agency level.
Injury and syndromic surveillance capabilities of the GEMSIS system are a hidden gem of OEMST that should be showcased and capitalized on
While initial metrics have been created as suggested for Zones, actual reporting on these metrics does not yet appear to be occurring at the regional or State level
There is no routine reporting to the EMSMDAC or EMSAC on utilization of medications, identification of outlier protocols/practices/medications, quality measures, patient destination, air medical utilization, or other specific clinical or operational items.(b) Specific data points:
- Data system: Georgia EMS Information System (GEMSIS) — NEMSIS-compliant
- Biospatial deployed for data visualization and analysis
- 24-hour data submission requirement
- Stroke registry: 83 hospitals participating, covering estimated 96% of all hospital stroke admissions
- Stroke registry integrated with GEMSIS, vital records, and hospital discharge databases
- CARES participation: active
- Trauma registry: maintained by OEMST; only designated centers required to submit
- Pilot patient armband program funded by GOHS for deterministic linkage of crash-EMS-hospital data
- TRAIN GA learning management system in use
- No annual report currently published (contemplated)
3G. Trauma System Status
(a) Direct quotes:Several presenters referred to the 'corridor of death' as a challenge to timely care due to lack of resources and long transport distances to definitive care.
he announcement of the closure of a Level 1 trauma center in Atlanta was made. This highlights the fragility of the system and may have a devastating impact.
It is counter to the public interest for a trauma center to cease (or even reduce) operations unexpectedly and without adequate notice for the system to adjust.(b) Specific data points:
- Designated trauma centers: 35 total
- 9 Level II (including 1 pediatric)
- 8 Level III
- 9 Level IV
- 2 burn centers
- GTC created 2007
- GTC funded by super-speeder fines and fireworks tax percentage
- Level I and II centers must be ACS verified to receive GTC funding; Level III and IV verified by OEMST
- No State trauma medical director
- Only designated centers required to submit to trauma registry
- Patients transferred directly out-of-state unaccounted for in registry
- Some regions must transport out-of-state to closest trauma center
- No requirement for trauma centers to report financial status
3H. Medical Direction
(a) Direct quotes:Medical direction is an area of great opportunity in Georgia.
With the hiring of a highly qualified State EMS medical director, this critical area has the leadership needed to be systematically improved.
Outside the urban areas, medical directors are almost uniformly unpaid.
here is Code which specifically provides immunity to EMS medical directors, this protection is voided by any form of paymen
Georgia is a 'home rule' State, and there is a perceived resistance to mandates of any sort that could supersede local authority. Unfortunately, this has extended to include national level guidance documents such as evidence-based guidelines (i.e., pain management) and EMS model clinical guidelines. This stance is an impediment to implementation of nationally vetted best practices
There is no formalized clinical peer review.
There is a dichotomous and diametrically opposite approach in patient care protocols.
The State's approach to locally developed EMS agency protocols leads to considerable variation in patient management by EMS personnel.
due to the culture of home rule, there is little to no guidance on what training or expertise is needed and/or required to perform both online and offline medical oversigh(b) Specific data points:
- Georgia has a State EMS Medical Director (recently hired at time of assessment)
- No State trauma medical director
- No regional medical director role well defined
- Medical director immunity voided by any payment — creates disincentive for compensation
- No medical director certification/recertification requirement
- No formalized peer review process
- No routine clinical or operational reporting to EMSMDAC or EMSAC
- Minimum protocol requirements cover only cardiac, stroke, and trauma
- No requirement for OEMST notification of scope of practice restrictions
3I. Communications and Infrastructure
(a) Direct quotes:Emergency medical communications in Georgia is established by local authorities through various operational approaches.
While 911 does exist throughout the State, there is no clear indication of what jurisdictions have 911 and with which capabilities.
management of the public safety answering point (PSAP) occurs on the local level with no State oversight or coordination
here is currently limited automated transfer of computer-aided dispatch (CAD) data to EMS
While there are interoperable communications in some communities, there are no functions in the existing system assuring Statewide communications from dispatch to ambulance, hospital to hospital, and ambulance to other public safety partners.(b) Specific data points:
- 911 exists throughout the State but capabilities vary and are not documented centrally
- Georgia Emergency Communications Authority (GECA) under GEMA tasked with guidance
- No State oversight or coordination of PSAPs
- Two new dispatch laws effective January 1, 2024: telephone CPR certification required; PSAP director training required
- No Statewide emergency medical dispatch system
- No specific number of PSAPs cited in the report
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (1995 Assessment)
This is a reassessment of the original 1995 assessment — a gap of 27 years.
Unlike the Kentucky report, the Georgia report does not include a dedicated "Progress on Prior Recommendations" section within each topic area. The report format uses only "Standard," "Status," and "Recommendations" sections. Progress from the 1995 assessment is referenced only incidentally:
Since the 1995 NHTSA Assessment, the composition of the EMS Advisory Council has been defined in rule." (Resource Management)
An improvement from the 1995 NHTSA Assessment, all 10 Regional EMS Directors and Regional EMS Training Coordinators report up to the OEMST." (Resource Management)
Since 1995, there has been significant growth in the number and distribution of rotor wing air ambulances." (Transportation)
The report also references the 2009 ACS report as a benchmark document, noting that several current focus areas "were previously noted as a part of the 2009 ACS report."
No systematic accounting of 1995 recommendation completion status is provided. The number of original recommendations that were completed, partially completed, or not completed cannot be determined from this report.SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall System Characterization
Historically, the State has done strong work in building a system that includes all the classic elements reviewed in a State EMS assessment.
he supportive, professional, and collegial relationships between the OEMST and the multitude of system partners. These sincere remarks spoke volumes about the culture of how many different people and groups are working together as a team to improve EMS.
The future of the EMS system in Georgia is bright given the willingness of system participants to continue thinking creatively about what patients and their communities really need and how they can best deploy the available resources to meet those needs.
The introduction uses Gone with the Wind quotes as a framing device, which is notably literary and distinctive for a NHTSA assessment report.
Structural Barriers Identified
1. Home rule culture — explicitly identified as an impediment to implementing evidence-based practices and clinical standardization
2. OEMST/GTC split — regulatory authority and funding authority housed in separate entities with declining alignment
3. Medical director liability/compensation paradox — immunity voided by payment
4. Unregulated EMS segments — fixed wing, special events, movie productions, first responders without licensure
5. Disparate specialty systems of care structures — each system has different regulatory, oversight, and funding mechanisms
6. No centralized coordination of EMS and trauma assets at state level
7. Declining GTC allocation — funding below statutory authorization since 2019
Transportation vs. Healthcare Framework
The report operates within the transportation/highway safety framework through NHTSA and GOHS sponsorship, but the TAT explicitly and repeatedly frames EMS as a healthcare system:
This continues to be the most appropriate home for the oversight of the emergency medical care system and EMS healthcare professionals.
The TAT applauds the Assembly's foresight in establishing the OEMST within the Department of Public Health (DPH), and heartily supports the OEMST remaining with the DPH.
he provision of EMS care and transportation, along with the assurance that specialty systems of care patients are transported to the most appropriate facility at the most appropriate time is a fundamental component of the Statewide health care system
The report recommends renaming OEMST "to more accurately reflect the mission and portfolio of activities to include all specialty systems of care."
Federal Funding Mechanisms Referenced
- Highway safety grant funds (GOHS investment in GEMSIS, DataMart, CODES project)
- CDC Coverdell cooperative agreement (stroke registry)
- EMSC program (federal)
- Pandemic response workforce grant funding (5 OEMST positions)
Greatest Strengths (as identified by the TAT)
- OEMST positioned within Department of Public Health — "most appropriate home"
- Collegial culture of collaboration among EMS stakeholders
- Robust GEMSIS data system with Biospatial — "laudatory," "hidden gem"
- 96% of stroke admissions captured in registry
- State EMS Medical Director recently hired
- 10-region organizational structure with zoning
- Emergency Cardiac Care program established 2017
- Infectious disease/special pathogens expertise (Emory University) — national leadership
- EMS education in high schools
- RAPBACK criminal background check program
- Strong preparedness system — "Georgia takes care of Georgia"
Most Critical Challenges (as identified by the TAT)
- Workforce shortages at all levels — "a serious problem without an easy solution"
- Home rule culture impeding clinical standardization
- OEMST budget insufficient; dependent on time-limited grants
- Declining GTC allocation to OEMST
- Closure of Level I trauma center during assessment — "fragility of the system"
- "Corridor of death" — geographic gaps in trauma access
- 54 counties without hospitals
- No formalized peer review or routine quality reporting
- Medical directors largely unpaid outside urban areas with liability disincentive
- Significant protocol variation across agencies
- No statewide EMD system
- No systematic tracking of 1995 recommendations
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
27-Year Gap Between Assessment and Reassessment
The original assessment was conducted in 1995 and this reassessment in 2022 — a 27-year gap. Unlike the Kentucky report, the Georgia report does not systematically track progress on 1995 recommendations, mentioning them only incidentally.
"Corridor of Death"
Several presenters referred to the 'corridor of death' as a challenge to timely care due to lack of resources and long transport distances to definitive care.
This phrase, attributed to multiple presenters, is a particularly striking characterization of geographic gaps in trauma access.
Level I Trauma Center Closure During Assessment
The announcement of the closure of a Level I trauma center in Atlanta occurred during the reassessment period itself. The TAT treats this as both a concrete example of system fragility and a catalyst for recommending financial status monitoring of trauma centers — a recommendation not commonly seen in NHTSA assessments.
Medical Director Liability/Compensation Paradox
here is Code which specifically provides immunity to EMS medical directors, this protection is voided by any form of paymen
This creates a structural disincentive for compensating medical directors. The TAT notes that outside urban areas, medical directors are "almost uniformly unpaid." This is a unique structural barrier.
Home Rule as Structural Barrier
The TAT explicitly identifies Georgia's "home rule" culture as an impediment to implementing nationally recognized best practices. This is documented as extending to resistance against evidence-based guidelines and model clinical guidelines — a finding that goes beyond typical local control concerns.
OEMST within Public Health
The TAT makes an unusually strong endorsement of OEMST's placement:
The TAT applauds the Assembly's foresight in establishing the OEMST within the Department of Public Health (DPH), and heartily supports the OEMST remaining with the DPH.
This is notable as an explicit endorsement of the healthcare (rather than transportation or public safety) framework for EMS governance.
Renaming Recommendation
Consider renaming OEMST to more accurately reflect the mission and portfolio of activities to include all specialty systems of care.
This recommendation acknowledges that the office's scope has expanded beyond its name.
Gone with the Wind Framing
The introduction uses two Gone with the Wind quotes to frame the assessment narrative. This literary device is distinctive among NHTSA assessment reports and reflects the TAT's characterization of the assessment as both acknowledging burdens and emphasizing optimism.
Astounding Paramedic Percentage
That is an astounding percentage of paramedics, easily eclipsing most States.36% of licensed practitioners at the paramedic level is specifically called out as exceptional nationally.
Super-Speeder and Fireworks Tax Funding
The GTC is funded through "super-speeder" ticket fines and a fireworks tax percentage — a notably specific and somewhat unusual funding mechanism for trauma care.
Emory Special Pathogens Program
Between 2014 and 2020, over 10,000 Georgia EMS personnel received awareness level training and over 1,000 received operator/technician level training.
Georgia's role in Ebola patient transport and the National Emerging Special Pathogens Training and Education Center represents a national-level capability housed within the state.
No Education Program Redesignation
he TAT was surprised to find that there is no redesignation process
The absence of an education program redesignation process is characterized as inconsistent with "most other States" and national accreditation practices — a finding the TAT explicitly flags as unexpected.
Essential Service Designation — Absent from Discourse
Unlike Kentucky (where essential service designation is a major theme appearing in multiple sections), the Georgia report does not discuss essential service designation as a gap or recommendation. The existing statutory language ("substantial importance") and zoning system appear to serve a functional, if not identical, role.
Analysis completed per standardized NHTSA State EMS Assessment framework. No synthesis or editorial interpretation has been applied. Findings are extracted as documented in the report.
Hawaii
Full Analysis
Hawaii 2019 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Hawaii
- Report type: Reassessment
- Date of site visit: October 14–18, 2019
- Year of publication: 2019 (cover letter dated January 9, 2020)
- Prior assessment year: Not explicitly stated; prior assessments referenced but year not given. 1978 EMS legislation cited as system origin. 1985 administrative rules cited as still in effect. 2006 HEMSIS deployment referenced.
- TAT members:
- Curtis Sandy, MD, FACEP, FAEMS
- Leslee Stein-Spencer, R.N., M.S.
- Peter Taillac, MD, FACEP, FAEMS
- Kyle Thornton, EMT-P, M.S.
- Tour Team: Curtis Sandy, MD; Keith Wages; Dave Bryson (NHTSA Facilitator)
- NHTSA facilitator: Dave Bryson
- Executive support: Susan Gillies
- Number of presenters/briefings: Not stated numerically; TAT traveled to all four counties
- Requesting agency: Hawaii Highway Safety Office and Department of Health's EMS and Injury Prevention Systems Branch (at the Legislature's request)
SECTION 2: STATE CONTEXT
- Population (as cited in report): 1.5 million citizens; over 10 million visitors annually (Introduction, p.8)
- Geographic characteristics: Island state; 4 counties separated by miles of water; separation makes sharing resources "a particular challenge"; diversity of cultures, languages, and traditions (Introduction, p.8)
- Number of counties/jurisdictions: 4 counties (City and County of Honolulu/Oahu, Kauai, Hawaii County, Maui); no EMS regions — counties function as primary operational units
- EMS system overview:
- Branch Chief and State EMS Medical Director: combined into single position (since 2006)
- State contracts for 911 ALS ambulance service with a single agency per county:
- Honolulu: City and County of Honolulu EMS
- Kauai: American Medical Response (AMR)
- Hawaii County: Hawaii County Fire Department
- Maui: American Medical Response (AMR)
- Contracts provide for total cost recovery; State-mandated billing and fee schedule
- 4 PSAPs (one per county)
- 4 District EMS Medical Directors (one per county)
- State mandates single ePCR system (HEMSIS), single medication formulary, statewide standing orders
- Paramedic training centralized under University of Hawaii Kapiolani Community College (KCC)
- 1 paramedic class per year with 15 student slots; 1,598 hours (800 clinical)
- EMT-B training: 380 hours for state licensure vs. 220 hours for NREMT only
- Licensing of ambulance EMS personnel: Department of Commerce and Consumer Affairs (DCCA)
- Scope of practice: Hawaii Medical Board
- 2 State-funded 911 helicopters (Hawaii County since 1994; Maui County since 2004)
- 2 private fixed-wing air ambulance operators (11 air bases)
- AMR provides non-emergency and interfacility transfers for all counties
- 19 EMS ground ambulance units added since 1991
- 3 active EMS-related advisory boards
- Community paramedicine legislation passed (HB1453 ACT140)
- Response time categories: 10 min urban, 15 min suburban, 20 min rural
- Notable demographic or socioeconomic factors cited: Diversity of cultures, languages, and traditions. Significant tourism burden (10 million visitors vs. 1.5 million residents). Island geography requiring air transport between islands for most tertiary care.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:The current EMS system appears to be focused on the provision of ambulance transport. There are many more elements to a comprehensive EMS system." (Regulation and Policy, p.12)(b) Data points: No current statewide EMS strategic plan. EMS Administrative rules written in 1985 — unchanged. Community paramedicine legislation (HB1453 ACT140) passed but not yet implemented. (c) TAT characterization: System described as focused on ambulance transport rather than comprehensive EMS. Rules "outdated and need to be revised." (d) Priority recommendations:
- Develop a five-year Strategic Plan identifying short- and long-term goals with stakeholders
- Update administrative rules to reflect current practice and national standards
- Legislature should update existing statute
3B. Funding and Financial Sustainability
(a) Direct quotes:Hawaii operates a centralized ambulance transportation system where the State contracts and pays for all 911 ambulance operations." (Transportation, p.22)
The billing structure utilized by the Branch assures the public they are not subject to over-billing or 'surprise' billing for emergency transports." (Resource Management, p.15)(b) Data points:
- State contracts and pays for all 911 ambulance operations (unique single-payer model)
- Total cost recovery through State billing and collection system with mandated fee schedule
- Contracts organized by county
- Centralized model does NOT include interfacility transfers, scheduled ambulance trips, or medical first response costs
- Trauma special fund: $7.4 million distributed to hospitals for personnel, training, equipment
- Critical Access Hospitals receive trauma fund portion though not designated
- Starting 2021: all facilities receiving trauma funds must submit registry data
- No dedicated EMS data manager position
- State funds support 2 helicopters; one aging with increasing maintenance costs; no replacement funds available
- Existing funding sources mentioned: tobacco tax, license plate fee, interest from State assets
- Potential additional sources suggested: DUI fees, moving violations, tourism tax
- PHEP and ASPR Hospital Preparedness Program identified as potential additional EMS funding
- DOT resources for data collection costs suggested
- KCC funds all permanent EMS training staff; satellite centers funded through Branch grants, tuition, fees
- KCC considering charging for CME in the future
- Conduct comprehensive cost analysis of entire EMS system
- Identify sustainable funding sources (DUI, moving violations, tourism tax) in addition to existing sources
- Investigate PHEP and ASPR Hospital Preparedness Program funding for EMS
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:There were conflicting statements on whether or not there is a shortage of EMS personnel. Three of the counties appear to be at full staffing with Oahu being the only county reporting shortages." (Human Resources, p.19)
There is no such certification or recognition of EMS personnel working for medical first responder entities." (Resource Management, p.16)(b) Data points:
- Significant disparity between nationally registered and State licensed EMS personnel numbers
- As of 2016, licensed personnel must maintain NREMT certification
- 3 of 4 counties at full staffing; Oahu only county reporting shortages
- 1 paramedic class per year, 15 slots; 1,598 hours (800 clinical)
- EMT-B state licensure: 380 hours (vs. 220 for NREMT only)
- Top 12 nationally for paramedic NREMT pass rate
- Additional paramedic classes limited by: clinical site availability, ride-along time, backfill/overtime costs for EMTs taking class
- Personnel on non-ambulance entities (fire first response, ocean safety, rescue, special events) NOT licensed — "potential liability... is significant"
- Uncertainty about ability to license persons not employed by ambulance service (referred to Attorney General)
- Hawaii does NOT participate in REPLICA
- No criminal background check/complaint investigation process clearly defined in statute/rule
- KCC sole training provider; satellite centers on 3 neighbor islands; students travel to Oahu for most clinical rotations
- EMS mental health: identified as national concern; Branch has statutory authority for this specific activity
- Conduct comprehensive statewide workforce study by county
- Support REPLICA legislation
- License all EMS personnel regardless of employment setting
- DCCA should issue licenses irrespective of ambulance employment
- Implement statewide EMD program
- Develop critical incident stress management and peer support programs
3D. Essential Service Designation
(a) Direct quotes:Initiate legislation to identify EMS as an essential public service." (Regulation and Policy Recommendations, p.13)(b) Data points: EMS is NOT currently designated as an essential public service in Hawaii. The TAT explicitly recommended legislation to establish this designation. (c) TAT characterization: Explicit recommendation — one of the few states in the corpus where essential service designation is affirmatively recommended. (d) Priority recommendation: Initiate legislation to identify EMS as an essential public service.
3E. Regulatory Fragmentation
(a) Direct quotes:The EMS Administrative rules, written in 1985, remain unchanged today." (Regulation and Policy, p.11)
Within the Department of Health's EMS and Injury Prevention Systems Branch (the Branch), the State EMS Director and State Medical Director positions are combined into a single position. This structure is a disservice to the EMS system." (Resource Management, p.14)(b) Data points:
- Administrative rules: unchanged since 1985 (34 years at time of visit)
- EMS legislation: 1978 (HRS 321-223)
- Multiple regulatory entities: DOH Branch (ambulance licensing, curriculum, communications, contracts); DCCA (personnel licensing); Hawaii Medical Board (scope of practice)
- Branch Chief and State EMS Medical Director: combined position (since 2006) — "disservice"
- 4 District EMS Medical Directors + agency medical directors — roles overlapping and "somewhat redundant"
- 3 EMS advisory boards — unclear if each accomplishing its mission; TAT suggests consolidation
- First responder and dispatch organizations NOT licensed by Branch
- Personnel not employed by ambulance services: uncertain licensure authority (referred to AG)
- Interfacility transfers (ground and air) outside regulatory system for billing, data, and oversight
- No EMD training or certification requirements
- No medical director authority to remediate/restrict/remove providers
- 1985 ambulance equipment checklist still in use
- Vehicle inspections: Branch lacks adequate staff; no evidence non-inspection is causing problems
- No requirement for private air ambulance submission to HEMSIS
- Separate Branch Chief and State Medical Director positions
- Update 1985 administrative rules
- Expand licensure to include first responder and dispatch organizations
- License all EMS personnel regardless of employer
- Consolidate three advisory boards into one
- Require interfacility transport reporting into HEMSIS
3F. Data and Evaluation Systems
(a) Direct quotes:Hawaii was one of the first States to begin Statewide participation in the national Cardiac Registry to Enhance Survival (CARES) which has allowed it to benchmark and dramatically improve the survival rates from cardiac arrest for its citizens." (Evaluation, p.42)(b) Data points:
- HEMSIS deployed 2006; NEMSIS 2.0 compliant; captures dispatch data
- All 911 agencies required to submit to HEMSIS
- Planning transition to NEMSIS 3.4
- Interfacility transfers NOT entered into HEMSIS (ground or air)
- Trauma registry: currently only designated trauma centers submit; ~5,000 trauma patients/year qualify
- Starting 2021: all facilities receiving trauma funds must submit
- EMS-hospital billing data linkage completed for 2008–2016 — discontinued 2017; efforts to resume when new HEMSIS deployed
- EMS-trauma registry linkage capability exists via patient identifier
- Epidemiologist available — described as "remarkable asset"; analyses guided decisions (e.g., removal of cricothyrotomy as permitted procedure)
- No dedicated EMS data manager position
- HEMSIS and trauma data used for: 2019 Strategic Highway Safety Plan, drug/opioid overdose analysis
- CARES participation: early adopter; "dramatically improved" cardiac arrest survival
- Quality assurance efforts exist but vary by agency
- No statewide QI system with agency medical director oversight
- Response time only measure for contract compliance — not evaluated against patient outcomes
- Continue efforts for automated linkage between HEMSIS, trauma registry, and hospital records
- Adopt nationally accepted performance measures (National EMS Quality Alliance)
- Require interfacility transport data submission to HEMSIS
- Link future stroke/STEMI registries to evaluate outcomes
- Continue CARES participation
- Hire dedicated EMS data manager
3G. Trauma System Status
(a) Direct quotes:Hawaii established a comprehensive trauma system over a decade ago." (Trauma Systems, p.29)(b) Data points:
- Trauma system established over a decade before 2019
- 1 Level I trauma center (Oahu)
- 7 Level III trauma centers (at least one per county as main ambulance receiving facility)
- 1 pediatric facility
- 1 Level III planning to transition to Level II; 1 acute care hospital seeking Level III in 2021
- Military Level II trauma center on Oahu (DOD personnel; civilian disaster participation)
- Adult burn center and pediatric burn center on Oahu (adult NOT at a designated trauma facility)
- No Level IV trauma center designation criteria
- State verification + ACS verification; transitioning to ACS exclusively
- Trauma special fund: $7.4 million distributed to hospitals
- Critical Access Hospitals receive trauma funds though not designated
- ACS Committee on Trauma system review: 2017; 63% of priority recommendations addressed or in process
- Trauma triage: CDC Field Trauma Triage Guidelines incorporated
- Neighbor islands transport all trauma patients to closest Level III
- Trauma registry: designated centers only; ~5,000 patients/year; can be manually linked to EMS data
- System involved in Stop the Bleed, traffic safety, senior falls, drowning prevention
- No formal STEMI or stroke center verification/designation (attestation only)
- Continue addressing 2017 ACS review recommendations
- Transition to exclusive ACS verification
- Develop Level IV trauma center criteria
- Implement automated EMS-trauma-hospital data linkage
- Publish annual trauma report
- Develop statewide trauma clinical management guidelines to reduce transfers to sole Level I
3H. Medical Direction
(a) Direct quotes:Within the Department of Health's EMS and Injury Prevention Systems Branch (the Branch), the State EMS Director and State Medical Director positions are combined into a single position. This structure is a disservice to the EMS system." (Resource Management, p.14)
Neither the District nor Agency EMS Medical Directors have statutory authority to remediate, restrict or remove EMS personnel from medical service if the director feels they are providing substandard or negligent medical care." (Medical Direction, p.35)(b) Data points:
- Branch Chief = State EMS Medical Director (combined since 2006)
- 4 District EMS Medical Directors (one per county); roles delineated in rule (§11-72-10); report to Branch Chief
- Each EMS agency and fire first-responder agency has a medical director — roles NOT in statute/rule; "overlapping and somewhat redundant" to District directors
- No authority for any medical director to remediate, restrict, or remove providers
- Standing orders used by all 911 agencies; last updated 2018 but not yet published at time of visit
- Standing order revision committee: not formally prescribed; does NOT include agency medical directors or prehospital personnel
- Standing orders available via smartphone/tablet app
- No requirement for medical director oversight of EMD
- Online medical direction generally from receiving hospital; agency MD consulted for unusual cases
- District MDs coordinate bariatric patient transport
- Interfacility transport agencies: no requirement for data submission or medical oversight by State
- No standard compensation for agency medical directors
- Separate Branch Chief and State Medical Director positions
- Replace 4 District Medical Directors with single State Medical Director (≥0.5 FTE)
- Require agency medical directors with clearly defined roles in statute/rule
- Ensure compensation for agency medical directors
- Provide medical director authority to remediate/restrict/remove providers
- Include agency MDs and prehospital personnel on standing order committee
- Update standing orders at least every 2 years using NASEMSO Model Guidelines
3I. Communications and Infrastructure
(a) Direct quotes:The lack of a comprehensive Emergency Medical Dispatch (EMD) / pre-arrival instruction program Statewide is a disservice to the residents of Hawaii." (Resource Management, p.14)(b) Data points:
- 4 PSAPs (one per county)
- Enhanced 911 available statewide (landline, cell, text)
- Statewide Medicom System — does NOT allow inter-county communication
- If cell phones down, counties isolated for medical communications
- Plan underway to transfer State radio system to county maintenance
- No standardized EMD training; no certified EMDs; no medical priority dispatch required
- No medical director involvement with EMD known
- Hawaii listed among FirstNet participating states — conflicting info received; Branch should engage
- EMS-fire-police interoperability within counties via tactical channels
- Create rule requiring PSAPs to have EMD system and certified EMDs with training/licensing standards
- Improve inter-county radio interoperability including data transmission and hospital integration
- Participate in FirstNet
- Support Next Generation 911
3J. Preparedness
(a) Direct quotes:Any disaster operation plan that does not include EMS is not a functional plan and leaves the State at risk." (Resource Management, p.15)(b) Data points:
- HIEMA (under Hawaii National Guard): statewide disaster coordination
- HHEM: healthcare resource coordination during emergencies; funded through DOH hospital preparedness grant
- Each county has a disaster plan including EMS
- ESF-8 documents do NOT mention EMS by name — gap identified
- HHEM developing new statewide disaster plan that will include EMS
- No direct connection between HHEM and Branch (collaboration increasing)
- Real-world responses: 2018 volcanic eruption (Hawaii County), 2018 floods (Kauai) — Honolulu IMT deployed
- SNS Chempacks: stored by Honolulu EMS
- Pandemic flu plan: 2008 (outdated at time of visit — pre-COVID)
- Ebola protocols developed: specialized ambulance units identified; dispatcher travel history screening
- H1N1: AMR airport unit provided 24-hour surveillance screening at Honolulu International
- Dengue fever 2017: Hawaii County Fire/EMS conducted patient surveillance in remote areas, collected blood samples
- Hospital Emergency Response Teams, Incident Management Assistance Teams, Incident Specialty Teams exist
- Multiple organizations with overlapping disaster missions — TAT suggests consolidation review
- Family reunification during inter-county patient movement: challenge being addressed with Red Cross
- Update ESF-8 to specifically include EMS
- Update 2008 pandemic flu plan
- Implement family reunification process with Red Cross
- Continue robust all-hazards exercise program including EMS
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
Prior assessment year not explicitly stated. Progress is primarily measured against the 2017 ACS Trauma System Consultation.
The Branch reports that 63 percent of these priority recommendations have been or are in the process of being addressed." (Trauma Systems, p.30) — referring to 2017 ACS recommendationsKey developments since prior assessment:
- HEMSIS deployed (2006); NEMSIS 2.0 compliant
- Trauma system established with Level I, III, and pediatric centers
- Trauma special fund ($7.4 million) established
- EMS-hospital billing data linkage completed (2008–2016)
- CARES participation: early adopter
- Community paramedicine legislation passed (HB1453 ACT140)
- Statewide standing orders and medication formulary maintained
- Stop the Bleed Day proclaimed by Governor (2019)
- EMS Cabinet formed for legislative advocacy
- 19 ambulance units added since 1991
- 2 helicopter programs established
- E911 universal including text
- Smartphone/tablet app for standing orders
- Administrative rules unchanged since 1985 (34 years)
- Combined Branch Chief/Medical Director position (since 2006)
- No EMD program
- No EMS strategic plan
- Interfacility transport outside regulatory system
- First responder personnel unlicensed
- No dedicated EMS data manager
- EMS-hospital data linkage discontinued (2017)
- Pandemic flu plan outdated (2008)
- EMS not in ESF-8
1. EMS workforce study
2. EMS system cost analysis
3. Require all ground and air ambulance care documented in HEMSIS
4. License all qualified EMTs and paramedics
5. Make licensure independent from employment
6. Hire EMS data manager
Formal tallies: Not documented in this report in systematic format. 2017 ACS recommendations: 63% addressed or in process.SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall characterization:The Hawaii Department of Health's EMS and Injury Prevention Systems Branch (the Branch) does not currently have the resources necessary to coordinate and nurture all of the elements in a comprehensive EMS system." (Introduction, p.8)
There is a strong emergency ambulance system that is highly regarded as serving patients well and providing uniform, high-quality care. With that said, emergency ambulances are but one piece of a comprehensive EMS system." (Introduction, p.8)
The concept of evolution rather than revolution is in order here." (Introduction, p.9)Structural barriers identified:
- Island geography: counties separated by water; sharing resources "a particular challenge"
- Only one Level I trauma center and only PCI/thrombectomy capability on Oahu
- Administrative rules unchanged since 1985
- Combined Branch Chief/Medical Director position
- Multiple regulatory entities (DOH, DCCA, Medical Board) with unclear boundaries
- Licensure tied to ambulance employment
- Interfacility transport entirely outside system oversight
- No dedicated EMS data manager
- Inter-county communications isolation
- EMS not named in ESF-8
The report explicitly describes the system as narrowly focused on "ambulance transport" and calls for expansion into a "comprehensive EMS system." The single-payer centralized model is described as a public utility approach. Community paramedicine legislation signals healthcare framework evolution.
Federal funding mechanisms:- Highway safety funds: Legislature requested assessment through Highway Safety Office
- PHEP and ASPR Hospital Preparedness Program grants: potential EMS funding sources identified
- HRSA EMSC program referenced
- DOT resources for data collection identified as potential funding
- Centralized single-payer 911 ambulance model: unique nationally; prevents surprise billing; cost-effective
- ALS commitment in rural areas
- CARES participation: early adopter; "dramatically improved" cardiac arrest survival
- Epidemiologist: "remarkable asset"
- EMS-hospital data linkage capability (2008–2016)
- Trauma special fund ($7.4 million)
- Comprehensive injury prevention programs
- Statewide standing orders with smartphone app
- Paramedic NREMT pass rate: top 12 nationally
- Strong preparedness cooperation including real-world responses
- "Uniform respect, support, commitment and good humor" of stakeholders
- Stop the Bleed Day — Governor's Proclamation
- Administrative rules unchanged since 1985
- Combined Branch Chief/Medical Director — "disservice"
- No EMD program — "disservice"
- No statewide EMS strategic plan
- No EMS data manager
- Unlicensed first responder personnel
- Interfacility transport outside system
- No STEMI/stroke designation
- Inter-county communications isolation
- Medical directors lack authority to remove providers
- EMS not in ESF-8
- Single Level I trauma center for entire state
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
Unique Single-Payer Centralized Ambulance Model
Hawaii's model of State-contracted, State-billed, single-payer 911 ALS ambulance service is described as "unique among all the States" and "unparalleled." The State mandates a single ePCR system, single medication formulary, and statewide standing orders. This creates uniform care but the TAT noted it is narrowly focused on ambulance transport to the exclusion of other comprehensive EMS system elements.
1985 Administrative Rules — Oldest Unrevised in Corpus
The EMS administrative rules have been unchanged since 1985 — 34 years at the time of the visit. This is the oldest set of unrevised rules documented in the corpus (Alaska: 2002; Connecticut: 10+ years; Michigan: 10+ years; Wisconsin: outdated but updated periodically).
Combined Branch Chief and State Medical Director — "Disservice"
The TAT used the word "disservice" for this structure — unusually direct language. The recommendation to separate the positions and replace four District Medical Directors with a single State Medical Director (≥0.5 FTE) would fundamentally restructure Hawaii's medical direction model.
Essential Service Designation — Explicit Recommendation
Hawaii is one of the few states in the corpus where the TAT explicitly recommended legislation to "identify EMS as an essential public service." Most reports note the absence of essential service designation but do not make a direct recommendation.
"Disservice" Used Twice — EMD and Combined Position
The TAT used the word "disservice" for both the lack of EMD and the combined Branch Chief/Medical Director position — the strongest language used in any section of this report and notable for a report with otherwise warm, respectful tone.
10 Million Visitors vs. 1.5 Million Residents
The EMS system serves a visitor population roughly 6.7 times the resident population annually — a unique demand ratio not documented in other assessed states.
CARES Early Adopter
Hawaii was "one of the first States" to participate in CARES, allowing benchmarking that "dramatically improved" cardiac arrest survival. This is one of the most concrete outcome improvements documented in the corpus.
EMS-Hospital Data Linkage — Created Then Discontinued
The Branch linked EMS records to hospital billing data for 2008–2016 — a capability most states in the corpus cannot achieve — but discontinued the linkage in 2017 for financial/technical reasons. Efforts to resume when new HEMSIS platform deploys.
EMS Surveillance for Infectious Disease
Hawaii County Fire/EMS conducted patient surveillance during the 2017 dengue fever outbreak, visiting remote areas and collecting blood samples. During Ebola, dispatchers screened for travel history. AMR provided 24-hour airport screening during H1N1. These represent EMS-public health integration beyond what other assessed states document.
Pandemic Flu Plan — 2008 Vintage (Pre-COVID)
The statewide pandemic flu plan dates to 2008 — notable given this assessment occurred in October 2019, less than 4 months before the first COVID-19 cases were identified globally. The TAT recommended updating it.
DOH Priority Response — Cover Letter
The report includes an unusual addendum: a January 9, 2020 cover letter from Branch Chief Dr. Alvin Bronstein listing 6 initial DOH priorities from the recommendations. This is the only report in the corpus with a formal state response attached.
Analysis produced using standardized NHTSA State EMS Assessment extraction framework. All quotes are from the Hawaii 2019 Reassessment report. No editorial synthesis applied.
Idaho
Full Analysis
Idaho 2024 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of Idaho
- Report type: Reassessment
- Date of site visit: June 24–27, 2024
- Year of publication: 2024
- Prior assessment year: 1993 (original assessment)
"tremendous progress has been made since the original 1993 Idaho Statewide EMS Assessment"
- TAT members:
- Dan Manz
- Christoph Kaufmann, MD, MPH, FACS
- Sabina Braithwaite, MD, MPH, FACEP, FAEMS
- Kyle Thornton, EMT-P, M.S.
- Alisa Habeeb Williams, NRP, B.S.
- NHTSA facilitator: Dave Bryson
- Executive Support: Susan Wiczalkowski
- Number of presenters/briefings: Not specified by count.
- Requesting agency: Idaho Transportation Department (ITD), Office of Highway Safety (OHS), in collaboration with the Bureau of EMS & Preparedness
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not stated as a specific figure. The report notes:
"Idaho is seeing significant population growth, with a shift to an older demographic and migration from more rural counties into the population centers. From 2010–2022, the population increased each year by an average of 1.8%."
- Geographic characteristics: Idaho is described as a rural and frontier state. The name derives from the Shoshone phrase meaning "gem of the mountains." The report references vast land area, rugged mountains, pristine water, and remote sections. Weather is identified as a limiting factor for air transport. Patients requiring high-level care are transported out of state to Salt Lake City, Seattle, Spokane, or Billings.
- Number of counties/jurisdictions: 44 counties
- EMS system overview:
- Lead agency: Idaho Department of Health and Welfare (IDHW), Bureau of EMS and Preparedness ("the Bureau")
- Bureau consists of four sections: Public Health Preparedness and Response (PHPR); State Communications Center (StateComm); Strategy, Quality, and Innovation (SQI); Systems of Care (SOC — EMS, TSE, EMSC)
- EMS Physician Commission (EMSPC): established in Idaho Code as independent rulemaking authority for clinical standards, scope of practice, patient care standards, and medical direction requirements
- EMS Advisory Committee (EMSAC): continues to function but was "established in, and then removed from, administrative rule" — has no statutory authority
- ~5,000 licensed practitioners; estimated 60% at EMT level; 40% are volunteers covering nearly 70% of Idaho's geography
- 3 CoAEMSP accredited paramedic programs
- 48 PSAPs
- 45 hospital facilities (including 2 rural clinics, 27 critical access hospitals)
- No Level I trauma centers in the state
- No formalized EMS regions (but 3 Regional Healthcare Coalitions, 6 TSE regions, 7 Public Health Districts, 5 OEM regions — with similar borders)
- EMS Compact member
- Time Sensitive Emergency (TSE) program with Governor-appointed TSE Council (rulemaking and designation authority)
- Notable demographic or socioeconomic factors cited: Significant population growth (1.8%/year average 2010–2022), shift to older demographics, migration from rural to population centers, declining volunteerism, "less government is best government" philosophy.
"Many Idahoans see less government as the best government. How to have agencies of State government play a useful leadership role in guiding and assuring the quality and consistency of the EMS system is a balancing act."
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:
"Like some of the State's long rural highways, Idaho EMS has reached something of a crossroads today."
"The legislature has completed two major studies of the EMS system that identified significant system needs. A recent analysis of EMS in each county provides a current snapshot of operations. These reports deserve public daylight and should serve as the foundation for a State strategic EMS plan."
"The Bureau has commissioned the completion of a plethora of reports on subjects such as volunteer EMS, system governance, and workforce concerns. The number and volume of these reports are impressive."
"The term 'sustainability' has been linked to Idaho's EMS system in recent years. That word raises existential questions about the future of both daily local operations and State EMS system oversight."
(b) Specific data points:
- No statewide strategic EMS plan exists
- Two major legislative studies completed
- County-by-county analysis completed — 845-page report with individual county reports
- Sustainability Task Force established
- Town hall meetings conducted
- No formalized EMS regions (despite overlapping regional structures in other programs)
(c) Report characterization: The TAT frames the state as being at a "crossroads" with extensive data gathered but not yet translated into a strategic plan. The existing reports are described as impressive in volume but needing to be converted to action.
(d) Priority recommendation status: Yes. Development of a statewide strategic EMS plan is the lead recommendation in Regulation and Policy.
3B. Funding and Financial Sustainability
(a) Direct quotes:
"The Bureau has an annual budget of approximately $3.65 million - $4.15 million dedicated specifically to EMS functions."
"Given the current authority and responsibility of the Bureau, the staffing and budget levels are insufficient to accomplish all statutory, regulatory, and organizational mandates."
"The Idaho legislature needs to understand that EMS sustainability begins at the Bureau."
"Ensuring Idahoans continue to be served by a system that is prompt, reliable, affordable, and medically sound is a challenge that will require changes across existing legislation, rule, policy, education, and finance elements."
(b) Specific data points:
- Bureau annual budget: $3.65M–$4.15M for EMS functions
- Two dedicated State funds generate approximately $2.3M–$2.7M for Bureau activities
- EMSPC funded through AEMT and Paramedic licensure fees (set by rule, not reviewed "in many years")
- TSE program: some dedicated funding from hospital designation fees
- PHEP and ASPR HPP federal grants support preparedness
- Grant funds used for ambulance vehicle and equipment purchases (inspected for intended use)
- Staffing gaps identified in: EMS training/education, licensure, compliance, administration, specialty systems coordination, medical oversight
(c) Report characterization: The TAT directly addresses the legislature, stating that "EMS sustainability begins at the Bureau" — an unusually pointed audience-specific statement. Staffing and budget are characterized as "insufficient" for statutory mandates.
(d) Priority recommendation status: Yes. Ensuring adequate resources and reviewing fee schedules are recommended.
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:
"Forty percent of the licensees are volunteers, who cover nearly 70% of the geography of Idaho."
"Media attention has highlighted shortages of EMS providers and wage issues in some areas of Idaho."
"changing demographics, an aging population, and community response expectations are making it harder for volunteers to continue meeting their needs"
"The challenge of declining volunteerism is not unique to Idaho and needs to be viewed as a natural evolution."
"Volunteerism in Idaho EMS represents a particular conundrum worth mentioning."
(b) Specific data points:
- ~5,000 licensed practitioners
- ~60% at EMT level
- 40% volunteers, covering ~70% of Idaho geography
- 3 accredited paramedic programs
- 845-page county-by-county EMS analysis completed
- Sustainability Task Force established
- Town hall meetings conducted
- EMS Compact membership (impact unknown)
- Idaho Community Health Emergency Medical Services (CHEMS) resources referenced
- EMR with ambulance certification permitted as minimum ambulance staffing (below EMT)
(c) Report characterization: The TAT characterizes declining volunteerism as a "conundrum" and a "natural evolution" rather than a crisis. The 40% volunteer/70% geography coverage ratio is presented as a core structural feature. The TAT recommends continuing sustainability work rather than emergency intervention.
(d) Priority recommendation status: Indirectly. Continuing sustainability work and expanding CHEMS utilization are recommended.
3D. Essential Service Designation
(a) Direct quotes:
"Assuring adequate representation of regional medical directors to provide clinical guidance in partnership with regional administrators' operational leadership should be integrated into the EMS system as an essential service initiative."
(b) Specific data points:
- The phrase "essential service" appears once, in the Medical Direction section, in the context of recommending regional medical director integration
- No explicit discussion of whether Idaho designates EMS as an essential service in statute
- No recommendation for essential service designation legislation
(c) Report characterization: The report does not address essential service designation as a standalone topic. The single reference is oblique, embedded in a medical direction recommendation.
(d) Priority recommendation status: Not documented in this report as a specific recommendation.
3E. Regulatory Fragmentation
(a) Direct quotes:
"The EMS Advisory Committee (EMSAC)... continues its mission, but without any statutory authority to provide advice or guidance to the Bureau."
"There is no authority for the Bureau to create an Advisory Committee, or to define its membership and terms for the purpose of advising and making recommendations to the Bureau."
"The State does not have the authority to set destination guidelines for EMS as that is the responsibility of each EMS agency medical director."
"There are no defined emergency medical services regions in Idaho."
"In numerous sections of this assessment, State level expectations have clearly been provided. However, those expectations must be consistently partnered with a mechanism for implementation as well as evaluation of effectiveness and loop closure"
(b) Specific data points:
- EMSPC: statutory rulemaking authority for clinical standards
- EMSAC: no statutory authority (removed from administrative rule)
- Bureau: no authority for destination guidelines
- No EMS regions (but 3 RHCCs, 6 TSE regions, 7 Public Health Districts, 5 OEM regions — all with "similar borders")
- No education program re-approval/renewal process (only initial approval)
- No EVOC training requirement for ambulance operators
- No EMD certification or training requirements
- No response time standards established
- Minimum ambulance staffing: EMR with ambulance certification + licensed driver (below EMT)
(c) Report characterization: The TAT identifies a structural gap between the Bureau's responsibility and its authority — particularly regarding EMSAC's lack of statutory standing and the Bureau's inability to set destination guidelines. The multiple overlapping regional structures without formal EMS regions is noted as an opportunity.
(d) Priority recommendation status: Yes. Authorizing and defining EMSAC functions is recommended.
3F. Data and Evaluation Systems
(a) Direct quotes:
"The trauma registry data is underutilized."
"It does not appear there is currently any routine reporting to the EMSPC on utilization of medications, identification of outlier protocols/practices/medications, quality measures, patient destination, air medical utilization, or other specific clinical or operational items that warrant close oversight."
"The Bureau is poised to provide salient and timely reporting on patient outcomes and system efficacy"
"While it would be optimal to customize reporting, initiating existing reports at regular intervals is preferable to awaiting perfection."
"For individual small rural and volunteer EMS agencies, it is unlikely that local resources will allow this analysis."
"Leadership for evaluation rests at the State level. This responsibility should not be divested to the regional level that has no significant infrastructure or resources"
(b) Specific data points:
- EMS data system: Idaho Gateway for EMS Patient Care Report (IGEMS-PCR)
- ImageTrend and Biospatial available
- Trauma registry in place; all facilities required to report regardless of designation
- Registry uses NTDB standard data set
- Epidemiologist reviews data quality
- Designation fees fund registry
- Data aggregated by Idaho Hospital Association through contract
- No routine clinical/operational reporting to EMSPC
- No epidemiology support from IDHW secured (recommended)
- Data submission: most agencies within a week, but regulatory language not updated
- Multiple large urban agencies participate in CARES
- Several larger agencies use ESO PCR software
- No HIE linkage for 911-to-discharge patient tracking
(c) Report characterization: The TAT uses "underutilized" repeatedly. Data infrastructure exists but is not being leveraged for routine reporting, quality improvement, or system evaluation. The TAT makes a notable philosophical statement that evaluation leadership must remain at the state level and cannot be delegated to regions lacking resources.
(d) Priority recommendation status: Yes. Extensive recommendations on near-concurrent reporting, routine metrics, HIE linkage, epidemiology support, and Biospatial/ImageTrend utilization.
3G. Trauma System Status
(a) Direct quotes:
"There are no Level 1 trauma centers in Idaho. Patients requiring a higher level of care than is available in Idaho are transported to Salt Lake City, Seattle, Spokane, or Billings."
"Idaho is a rural and frontier state with 44 counties incorporating 45 facilities including two rural clinics."
"Multiple designated trauma centers within close proximity of a Level II trauma center are duplicative."
(b) Specific data points:
- TSE legislation passed 2014; TSE Council and regional committees established 2015; first designation 2016
- 29 trauma-designated facilities of 45 eligible (70% of full-service hospitals, 64% of all facilities)
- Level II adult: 4
- Level II pediatric: 1
- Level III: 5
- Level IV: 19
- No Level I centers
- All Level II centers ACS verified; Level III state verified
- Voluntary designation using ACS or State criteria
- 6 TSE regional committees
- TSE Council: 11 appointed seats + 6 regional chairs; Governor-appointed; has rulemaking and designation authority
- Transfer agreements required for all TSE designations
- ~84% of Idahoans within 30-minute drive time of trauma center
- Air transport covers entire state population
- Stroke designation: Levels I–III
- STEMI designation: Levels I–II
- Pediatric Readiness Recognition Program: voluntary (Pediatric Capable, Advanced, Expert)
- Pediatric Readiness Assessment completed by hospitals
- 27 critical access hospitals
(c) Report characterization: The TAT praises the TSE program as a "particular strength" with commendable progress since 2014. However, the absence of Level I trauma centers and dependence on out-of-state facilities for highest-acuity care is a structural reality. The concern about duplicative trauma centers near Level IIs is a resource optimization point.
(d) Priority recommendation status: Yes. Needs assessment for optimal system configuration, codified statewide triage guidelines, and regional/statewide registry data analysis are recommended.
3H. Medical Direction
(a) Direct quotes:
"Medical direction is arguably the strongest pillar of the EMS system in Idaho, in significant degree due to the longstanding vigorous engagement of the Chair of the EMS Physician Commission."
"There is no formally designated Idaho State EMS Medical Director. This was a gap identified in the original 1993 NHTSA assessment, which has been echoed in multiple documents and remains valid today."
"While the Chair of the EMSPC is considered the de facto State medical director by the Bureau, there is significant value in investing a specific individual with the title and authority of that position."
"Significant institutional memory, leadership experience, and statewide and nationwide networks are centered in the current Chair of the EMSPC. It is critical that a continuity of operations plan be created and implemented for this position"
"the State medical director should be incorporated into the leadership in the Bureau's organizational chart"
"The prior recommendation for creation of a State medical director position should be of the highest priority."
(b) Specific data points:
- No formally designated State EMS Medical Director (gap since 1993 — 31 years)
- EMSPC Chair serves as de facto State medical director
- EMSPC has statutory rulemaking authority for clinical standards, scope of practice, patient care standards, medical direction requirements
- EMSPC reviews disciplinary actions, peer review process
- Model State protocols developed; adopted by "majority of BLS and ILS agencies"
- Work accomplished using "entirely volunteer resources" — described as "exemplary"
- No routine clinical/operational reporting to EMSPC
- No continuity of operations plan for EMSPC leadership
- No regional medical director framework formally established
(c) Report characterization: This is one of the most paradoxical findings in the corpus: medical direction is simultaneously described as "arguably the strongest pillar" while also having no formally designated State EMS Medical Director — a gap persisting for 31 years since the original assessment. The TAT explicitly calls this "the highest priority" and raises succession concerns.
(d) Priority recommendation status: Yes. Creating and staffing a State EMS Medical Director position with enumerated authority, compensation, and liability protection is recommended as a top priority.
3I. Communications and Infrastructure
(a) Direct quotes:
"The State of Idaho's current enhanced 911 (E911) network is comprised of many telephone company networks designed and installed more than 40 years ago and remains largely unchanged today."
"there are no requirements for Idaho to utilize certified Emergency Medical Dispatch (EMD) in PSAPs"
"There are no required EMD training or certification standards. Medical director involvement with EMD systems is not a requirement."
(b) Specific data points:
- 48 PSAPs
- E911 network based on 40+ year old telephone company infrastructure
- E911 Phase II enabled (wireless location)
- Text-to-911 capability available at primary PSAPs
- NG911 in progress
- StateComm: collocated with Idaho State Police Dispatch in Meridian — 41 mountaintop radio base stations providing statewide coverage
- VHF spectrum primary; some agencies on 700 MHz for interoperability
- Two dedicated channels patchable to 700 MHz system
- StateComm can determine hospital capacity for MCI patients
- StateComm receives ANI/ALI transferred 911 calls from PSAPs but ICERD software requires manual entry
- No EMD certification standards
- No EMD training standards
- No medical direction requirement for EMD
- Emergency Communications Officers must be POST certified
- No CAD-to-ePCR automated data transfer requirement
(c) Report characterization: StateComm is praised as "envied by many States" and a valuable resource. However, the 40-year-old E911 infrastructure and absence of statewide EMD are identified as gaps. The TAT commends NG911 progress.
(d) Priority recommendation status: Yes. EMD requirement, dispatch QA integration, automated data transfer, and interoperability gap analysis are recommended.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (1993 Assessment)
This is a reassessment of the original 1993 assessment — a gap of 31 years.
The report does not include a formal "Progress on Prior Recommendations" section. References to the 1993 assessment are limited:
"tremendous progress has been made since the original 1993 Idaho Statewide EMS Assessment" (Introduction)
"There is no formally designated Idaho State EMS Medical Director. This was a gap identified in the original 1993 NHTSA assessment, which has been echoed in multiple documents and remains valid today." (Regulation and Policy)
"The prior recommendation for creation of a State medical director position should be of the highest priority." (Medical Direction)
The State EMS Medical Director gap is the only 1993 recommendation explicitly tracked in this report — and it remains unfulfilled after 31 years.
No systematic accounting of 1993 recommendation completion status is provided.
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall System Characterization
"Like the rugged Idaho mountains, the State's EMS system is built to endure."
"Idaho has been able to build the system it has today with good leadership and strong public support."
"Like some of the State's long rural highways, Idaho EMS has reached something of a crossroads today."
"Describing the choices to be made and implications of action or inaction in clear understandable language for the public and policy makers is a challenge."
The introduction uses mountain/highway metaphors to frame Idaho's EMS system. The tone is respectful but more urgently forward-looking than the other reports in the corpus, using "crossroads" and "sustainability" as organizing themes.
Structural Barriers Identified
1. No State EMS Medical Director — gap persisting 31 years from original 1993 assessment; characterized as "the highest priority"
2. No statewide strategic EMS plan — despite extensive data collection including an 845-page county analysis
3. EMSAC without statutory authority — advisory committee removed from rule, functioning without legal standing
4. Declining volunteerism — 40% of licensees are volunteers covering 70% of geography, facing demographic pressures
5. No Level I trauma centers — all highest-acuity patients must leave the state
6. Anti-government culture — "less government is best government" creates a balancing act for state EMS oversight
7. Bureau understaffed/underfunded — "insufficient" for statutory mandates
8. No statewide EMD — standard finding across the corpus
9. Aging 911 infrastructure — 40+ year old telephone networks
10. Data underutilization — registry data collected but not leveraged for routine reporting
11. No education program re-approval process — only initial approval exists
12. Bureau authority gaps — no authority for destination guidelines, no authority to create advisory committee
Transportation vs. Healthcare Framework
The report is co-sponsored by the Idaho Transportation Department and the Office of Highway Safety through NHTSA. However, the TAT explicitly frames EMS as healthcare:
"EMS is at its core healthcare and thus cannot credibly exist without medical oversight"
The Bureau's placement within the Department of Health and Welfare is endorsed:
"This is the most appropriate home for the oversight of the emergency medical care systems and EMS healthcare professionals."
"Wherever the future home of EMS in Idaho government is, a tight linkage with public health is essential."
The second quote implies potential future organizational changes are being discussed — a finding worth tracking.
Federal Funding Mechanisms Referenced
- Section 402 highway safety funds
- CDC PHEP grants
- ASPR HPP grants
- EMSC grant (implied)
- State grant funds for vehicles/equipment
Greatest Strengths (as identified by the TAT)
- StateComm — "envied by many States"
- TSE program — "particular strength," commendable growth in hospital designations
- EMSPC clinical leadership — "arguably the strongest pillar"
- Pediatric EMS and EMSC programs — breadth and depth of data, pediatric readiness focus
- Preparedness integration — EMS fully integrated with public health preparedness, 3 regional healthcare coalitions, 6 major activations in 7 years
- Model State protocols — adopted by majority of BLS/ILS agencies, created by volunteer resources
- 845-page county analysis — comprehensive data gathering (though not yet translated to action)
- Trauma registry — all facilities required to report regardless of designation
- 84% of population within 30-minute drive time of trauma center
- Mental health initiatives — first responder wellness efforts
- EMS Compact membership
- Infectious disease transport planning — proactive thinking despite low probability
Most Critical Challenges (as identified by the TAT)
- State EMS Medical Director vacancy — 31-year unfulfilled recommendation, "the highest priority"
- No statewide strategic EMS plan
- EMSAC without statutory authority
- Volunteer/career transition — 40%/70% volunteer coverage facing decline
- Bureau understaffing — gaps across multiple program areas
- No Level I trauma center in state
- Data underutilization — "underutilized" repeated
- No EMD standards
- Anti-government culture complicating state-level oversight
- Single-point-of-failure risk in EMSPC Chair leadership
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
31-Year Unfulfilled Recommendation
The State EMS Medical Director position was recommended in the 1993 assessment and remains unfilled in 2024 — a 31-year gap. This is one of the longest-documented unfulfilled recommendations in the NHTSA assessment corpus. The TAT explicitly connects it to the original assessment:
"This was a gap identified in the original 1993 NHTSA assessment, which has been echoed in multiple documents and remains valid today."
De Facto vs. De Jure Medical Director Paradox
Medical direction is simultaneously described as "arguably the strongest pillar" while having no formally designated State EMS Medical Director. The EMSPC Chair serves as de facto medical director through "entirely volunteer resources." This creates both a succession risk and a structural paradox where the strongest system element is also the most vulnerable:
"Significant institutional memory, leadership experience, and statewide and nationwide networks are centered in the current Chair of the EMSPC. It is critical that a continuity of operations plan be created and implemented"
Anti-Government Culture as Structural Factor
"Many Idahoans see less government as the best government. How to have agencies of State government play a useful leadership role in guiding and assuring the quality and consistency of the EMS system is a balancing act."
This cultural factor is explicitly acknowledged as shaping the limits of state EMS system development. While Georgia's "home rule" culture is described as an impediment, Idaho's anti-government sentiment is framed as a "balancing act" requiring diplomatic navigation.
"Sustainability" as Existential Frame
"The term 'sustainability' has been linked to Idaho's EMS system in recent years. That word raises existential questions about the future of both daily local operations and State EMS system oversight."
The TAT frames sustainability as raising "existential questions" — notably strong language for an NHTSA assessment.
845-Page County Report — Data Without Action
The Bureau commissioned detailed county-by-county analysis resulting in an 845-page report. The TAT characterizes this as impressive but explicitly calls for it to be converted to a strategic plan:
"These reports deserve public daylight and should serve as the foundation for a State strategic EMS plan."
No Level I Trauma Center in State
Idaho is the only state in this corpus (so far) with no Level I trauma center. All highest-acuity trauma patients must be transported to Salt Lake City, Seattle, Spokane, or Billings. This is a fundamental system configuration that distinguishes Idaho from the other states analyzed.
EMSAC: Statutory Orphan
"The Committee continues its mission, but without any statutory authority"
An advisory committee that was "established in, and then removed from, administrative rule" and continues functioning without legal authority is a distinctive regulatory anomaly.
Potential Organizational Change Signaled
"Wherever the future home of EMS in Idaho government is, a tight linkage with public health is essential."
This phrasing implies discussions about relocating EMS governance may be underway — a finding not explicitly stated but implied by the conditional language.
Volunteer "Conundrum" Framing
"Volunteerism in Idaho EMS represents a particular conundrum worth mentioning."
The TAT frames volunteerism as simultaneously essential (covering 70% of geography) and unsustainable (declining demographics), using "conundrum" rather than crisis language. The recommendation to view this as "natural evolution" rather than failure is a distinctive philosophical stance.
Idaho's "Crossroads" Metaphor
The TAT uses "crossroads" as the central framing metaphor — the state has accumulated extensive knowledge (reports, studies, data) but has not yet translated it into strategic action. This positions the reassessment as a potential inflection point.
Minimum Staffing Below EMT
Idaho permits EMR with ambulance certification (rather than EMT) as minimum ambulance staffing. This is below the NHTSA standard but reflects rural/frontier staffing realities.
Curtis Sandy — TAT Member and Idaho EMSPC Chair
Dr. Curtis Sandy appears on multiple TAT rosters in this corpus (Iowa 2015, Georgia 2022) and is also the longstanding Chair of the Idaho EMSPC. He is not listed as a TAT member for the Idaho 2024 assessment, which is appropriate given his role as the state's de facto medical director. However, his extensive involvement in NHTSA assessments nationally adds context to the institutional knowledge dimension.
Analysis completed per standardized NHTSA State EMS Assessment framework. No synthesis or editorial interpretation has been applied. Findings are extracted as documented in the report.
Iowa
Full Analysis
Iowa 2015 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of Iowa
- Report type: Reassessment
- Date of site visit: April 27–30, 2015
- Year of publication: 2015
- Prior assessment year: Not explicitly stated by year in the report; referred to as "last NHTSA assessment." The trauma system plan is referenced as dating to 1994 and the trauma system to 2001, but the prior assessment date is not specified.
- TAT members:
- Christoph R. Kaufmann, MD, MPH, FACS
- Terry Mullins, MBA
- Curtis C. Sandy, MD, EMT-T, FACEP
- Kyle Thornton, EMT-P, B.U.S.
- Jolene R. Whitney, MPA
- NHTSA facilitator: Susan McHenry, MS
- Executive Support: Janice D. Simmons, BFA
- Number of presenters/briefings: Over 25 presenters
"For the first day and a half, over 25 presenters from the state provided in-depth briefings on EMS and trauma care."
- Requesting agency: Iowa Department of Public Health, Bureau of Emergency and Trauma Services (BETS)
SECTION 2: STATE CONTEXT
- Population (as cited in report): "over three million" residents (approximately 3 million)
- Geographic characteristics: The report emphasizes Iowa's rural character. The introduction states:
"The over three million residents of Iowa live in a state that has a rich tradition of history and service."
"the majority of its population in cities, has a large rural population – a challenge for optimizing trauma care"
The report references bordering states (particularly Omaha, Nebraska) for out-of-state specialty care. Agriculture is described as the state's economic foundation. The report notes that "approximately 70 percent" of national traffic fatalities occur on rural highways, framing Iowa's rural geography as directly relevant to the EMS mission.
- Number of counties/jurisdictions: 99 counties
- EMS system overview:
- Lead agency: Iowa Department of Public Health (IDPH); Bureau of Emergency and Trauma Services (BETS) formed in 2014 by merging the former Bureau of EMS and the Center for Disaster Operation and Response
- BETS is one of five Bureaus in the Division of Acute Disease Prevention, Emergency Response and Environmental Health
- Two advisory councils: EMS Advisory Council (EMSAC) and Trauma System Advisory Council (TSAC)
- Quality Assurance and Standards & Protocols (QASP) subcommittee under EMSAC
- System Evaluation Quality Improvement Subcommittee (SEQIS) under TSAC
- 333 fully certified ambulance agencies
- 144 "transport agreement" agencies
- 436 non-transporting agencies
- Total: 931 authorized service programs (combined, as referenced in the inspection discussion)
- 18 air ambulance services
- 18 institutions providing EMS education
- ~11,771 certified EMS caregivers
- 117 PSAPs across 99 counties
- 118 hospitals participating in the inclusive trauma system
- No formalized EMS or trauma system regions
- Notable demographic or socioeconomic factors cited: The report emphasizes Iowa's agricultural economy, rural character, and volunteer EMS tradition. No specific socioeconomic data (income, poverty rates, etc.) is cited.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:
"While BETS has regulatory authority for system planning, the Emergency Medical Services Advisory Council 'shall advise the director and develop policy recommendations concerning the regulation, administration and coordination of emergency medical services in the state'"
"Each county is eligible to receive EMS System Development Grants each year... In return for these grants, each county must develop and maintain a county-wide strategic EMS plan."
"A statewide trauma system plan was developed in 1994... The trauma system plan is now outdated."
"There are no formalized EMS or trauma system regions in Iowa."
"There was near universal calls for regionalization of EMS and trauma activities by presenters."
(b) Specific data points:
- 99 counties, each developing individual EMS system plans as a condition of grants
- 52 Iowa EMS system standards established in the System Standards Self-Assessment Tool
- No formalized EMS or trauma regions
- Statewide trauma plan developed 1994, characterized as "outdated"
- Public health/emergency preparedness had previously adopted 6 regions, which were "abandoned when they were not found to be effective"
(c) Report characterization: The TAT characterizes the absence of regionalization as a major gap, noting "near universal calls for regionalization" from presenters. County-level planning exists but there is no statewide coordination framework.
(d) Priority recommendation status: Yes. Regionalization appears as a recommendation in multiple sections: Regulation and Policy, Resource Management, Transportation, Communications, Trauma Systems, Evaluation, and Preparedness. It is the single most pervasive recommendation across the entire report.
3B. Funding and Financial Sustainability
(a) Direct quotes:
"The FY 2013 appropriation for BETS was $2.49 M and grants payable were $1.66 M leaving $830,000 to support the remaining activities."
"Funding is always a challenge for state EMS and other government offices. As with many states, there is a lack of interest and understanding of the needs and financial requirements on the part of the legislature and public of an EMS and trauma system."
"Some local governments have long received EMS at a huge discount due to the dedication of the volunteers in rural areas. Now that this resource is shrinking, local governments have difficulty finding funds to continue the provision of this critical safety net service."
"Many service programs do not bill for their services instead relying upon taxpayer support. For service programs that do bill, there is not a consistent method for the development of a fee structure which is tied to the cost for system readiness."
(b) Specific data points:
- BETS FY 2013 appropriation: $2.49 million
- Grants payable: $1.66 million
- Remaining for all other activities: $830,000
- Funding sources: general fund, federal Block grant, Flex grant, HPP/PHEP grants, EMSC grant, Highway Traffic Safety grant
- County EMS System Development Grants allocated annually by legislature (amount not specified); funded from legislative allocation plus provider certification fees and commemorative birth/marriage certificate revenue
- BETS has authority to set certification fees but not for program authorizations or trauma center verifications
- No fees assessed for inspections or authorization processes
- Trauma staff: 1.3 FTE dedicated to trauma system
- No state EMS Medical Director funded (position vacant "for a number of years")
- Department requested authority for internal fund transfer for epidemiologist/data analyst and regional coordinator — status not resolved
(c) Report characterization: The TAT characterizes funding as "always a challenge" and describes the legislature and public as lacking "interest and understanding." The $830,000 remaining after grants is implicitly described as inadequate for the scope of BETS responsibilities across 931 service programs and 118 hospitals.
(d) Priority recommendation status: Yes. Creation of "dedicated and sustainable funding sources" is recommended. Fee authority for authorizations and verifications is recommended. A statewide billing study is recommended.
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:
"There is a general sense that, especially in the rural agencies, the age of those available to serve their communities is increasing. This concern is due to, and exacerbated by, the waning availability of younger individuals willing to volunteer."
"The decrease of volunteerism was mentioned multiple times; this is an issue seen nationally, and one unlikely to abate."
"The most important component of the EMS system that serves the approximately three million Iowa residents is this cadre of certified caregivers."
(b) Specific data points:
- ~11,771 certified EMS caregivers:
- EMT: 6,675 (over half)
- EMT-Intermediate/A-EMT: 759
- EMT-P: 337
- Paramedic and "Paramedic Specialist": 2,731
- 18 EMS education institutions
- BETS transitioning out multi-level paramedic designation
- Workforce assessment completed by BETS providing "clear understanding of issues"
(c) Report characterization: The TAT characterizes declining volunteerism as a systemic challenge that is "unlikely to abate." The workforce is described in terms of aging volunteers in rural areas rather than acute crisis language. The TAT recommends continued recruitment and retention strategies.
(d) Priority recommendation status: Indirectly. Regionalization and consolidation are recommended as workforce solutions. No dedicated workforce funding recommendation is made.
3D. Essential Service Designation
(a) Direct quotes:
"Iowa does not have the provision of EMS as a statutory responsibility of counties, townships or cities, leading to the common issue of EMS not being seen as an essential service, which the public most certainly expects."
"The Iowa legislature should consider the addition of EMS to the list of responsibilities of counties, townships, and cities."
(b) Specific data points:
- EMS is not a statutory responsibility of any level of local government in Iowa
(c) Report characterization: The TAT explicitly identifies the absence of essential service designation and frames it as inconsistent with public expectation. This is one of the clearest statements on essential service designation in the corpus to date.
(d) Priority recommendation status: Yes. "The State Legislature should consider action to establish county and/or municipality responsibility for the assurance of EMS response within given jurisdictional borders."
3E. Regulatory Fragmentation
(a) Direct quotes:
"There is a dizzying number of EMS agencies; 333 fully certified ambulance agencies, 144 agencies certified as 'transport agreement' agencies, and 436 non-transporting agencies."
"With this in mind, the BETS ability to assure the inspection of all of these agencies every three years is difficult to conceive."
"there is no mechanism in place for BETS to assure all areas of the state are covered resulting in overlaps of service areas between providers"
"there is no oversight for dispatching ambulances across county lines creating situations where the closest ambulance may not be dispatched"
"PSAP operations and training are not regulated by the Department and BETS does not have the authority to certify emergency medical dispatch (EMD) staff or to require that PSAPs use EMD protocols."
"There are 99 counties in Iowa representing separate EMS systems."
(b) Specific data points:
- 931 total authorized service programs
- 4 regional coordinators conducting inspections every 3 years across all 931 programs
- 117 PSAPs — outside BETS regulatory authority
- 99 county-based EMS systems with no multi-county coordination structure
- No required mutual aid agreements
- No accounting process for total number of transport/non-transport vehicles
- No standardized drug, supply, or equipment list
- No air medical activation protocol exists
- Some services reported "leveraging the agreement to pick and choose calls"
(c) Report characterization: The TAT uses the word "dizzying" to describe the number of agencies and characterizes BETS' ability to inspect them all as "difficult to conceive." The 99-county fragmentation is identified as a structural problem addressed through the pervasive regionalization recommendation.
(d) Priority recommendation status: Yes. Regionalization, consolidation, and collaboration are recommended across multiple sections.
3F. Data and Evaluation Systems
(a) Direct quotes:
"EMS call data submission is required for all EMS service programs, though the non-transport services have not reported consistently. This has lead to the questioning of the quality and completeness of the data that is submitted."
"The state is prepared for NEMSIS 3 data submission but does not have a timeline to begin using the dataset."
"the majority of quality assurance activities are left to the local service and medical director. Each service is required to have a CQI plan approved by the medical director and seems to mostly focus on chart audits."
"There was testimony that cumbersome PCRs or the use of paper charts can hinder any meaningful review and feedback."
(b) Specific data points:
- EMS data system: transitioning to ImageTrend product
- Trauma registry: also transitioning to ImageTrend (go-live July 1, 2015)
- EMS data submitted to National EMS Information System (NEMSIS)
- Trauma data submitted to National Trauma Data Bank
- NEMSIS 3 ready but no timeline for implementation
- Peer-review data protected by statute from discoverability
- University of Iowa Injury Prevention Research Center involved in data analysis
- BETS tracked benchmarks: vital signs documentation, GCS, aspirin for cardiac, neurologic exams for stroke, scene times for trauma, lights/siren usage
- No epidemiologist position filled (requested)
- Paper charts still in use at some agencies
- Non-transport services not reporting consistently
(c) Report characterization: The TAT characterizes data quality and completeness as questionable, particularly for non-transport services. The transition to ImageTrend for both EMS and trauma is presented as an opportunity for data linkage, but this has not yet been realized.
(d) Priority recommendation status: Yes. Multiple recommendations on data submission compliance, ImageTrend adoption, regionalized evaluation, and epidemiologist position.
3G. Trauma System Status
(a) Direct quotes:
"Mortality for a given severe injury or combination of injuries in rural areas of the U.S. is twice as high as it is in urban areas – this is related to time, distance, and availability of surgical care."
"Since the initial implementation of the trauma system in 2001, further system maturation has been slow."
"The goal for Iowa's trauma system was presented as 'to match the patient's medical needs to existing medical resources.' Although this was a natural and appropriate concept when starting development of a statewide trauma system, as the system matures the paradigm should be reversed to say the goal is 'to provide medical resources required to meet existing patient needs.'"
"this protocol results in some critically-injured patients being transported to Level IV trauma centers. In many cases, it would minimize morbidity and mortality to transport the patient to a Level I or II trauma center 45 or 60 minutes away"
"The magnitude of preventable trauma mortality in Iowa is not known."
"success of this effort will be important to many across the U.S. as Iowa will then be able to set a new standard for quality rural trauma care. This will not be possible with only 1.3 FTEs dedicated to trauma system maintenance and improvement."
(b) Specific data points:
- Inclusive trauma system with all 118 hospitals participating (mandatory participation, voluntary verification level)
- 22 urban hospitals
- 6 rural referral hospitals
- 8 rural hospitals
- 82 critical access hospitals
- Trauma center levels:
- Level I: 2 (ACS VRC verified)
- Level II: 2 ACS VRC verified + 2 state verified = 4 total
- Level III: 19 state verified
- Level IV: 93 state verified (application only)
- 1 ABA verified burn center (University of Iowa)
- 1 Level I pediatric trauma center (Children's Hospital, University of Iowa)
- 1 Level II pediatric trauma center (Blank Children's Hospital, Des Moines)
- Trauma system plan: 1994 (outdated)
- Trauma system implemented: 2001
- ~40 trauma reverifications per year
- Trauma staff: 1.3 FTE
- No interfacility transfer protocols for trauma patients
- No trauma regions
- No state trauma medical director
- No preventable mortality study completed
- Current triage protocol: 30-minute threshold for bypass to Level I/II — TAT argues this should be 45-60 minutes for critically injured patients
- Pediatric-specific training not mandatory, but PALS "taught widely"
- Air ambulance "frequently utilized" for interfacility transport; no state guideline for air activation
- "Reluctance of local EMS agencies to consistently accept interfacility transports for fear of depleting local resources"
(c) Report characterization: The TAT characterizes trauma system maturation as "slow" since 2001. The paradigm reversal quote — shifting from matching patients to existing resources toward providing resources to match patient needs — represents a significant conceptual reframing. The TAT explicitly calls for Level V designation to differentiate among the 93 Level IV centers.
(d) Priority recommendation status: Yes. Extensive trauma recommendations including updated plan, Level V legislation, revised triage guidelines, interfacility protocols, preventable mortality study, additional FTEs, and regional development.
3H. Medical Direction
(a) Direct quotes:
"The State EMS Medical Director position has been vacant for a number of years. Several presenters suggested that the lack of a medical director has handicapped system progress."
"While funding is always a concern, the lack of the clinical expertise of a state level physician medical director for the BETS programs is a significant disservice to the EMS, trauma, preparedness, and stroke/STEMI stakeholders."
"This may be the highest priority for the BETS at this time."
"Medical director expertise and involvement varies greatly across the state and there was testimony that there are many medical directors that have minimal involvement."
"medical directors are allowed to omit portions of the statewide protocols. This practice appears to contradict the requirement of meeting or exceeding the minimum standard of care established by the statewide protocols."
"There is no formal regionalization of medical direction"
"there is no formal medical director organization"
(b) Specific data points:
- State EMS Medical Director: vacant for "a number of years"
- No state trauma medical director
- Medical directors required to attend one workshop within first year; no further education required
- Medical directors can omit portions of statewide protocols
- Criminal and civil liability protections exist but no administrative liability protection
- No medical director organization in Iowa
- No air medical activation protocol
- QASP subcommittee focuses on protocols and scope of practice
(c) Report characterization: The TAT characterizes the vacant State EMS Medical Director position as potentially "the highest priority for the BETS at this time" and the vacancy as a "significant disservice." Medical director involvement is described as varying "greatly" with "many" having "minimal involvement."
(d) Priority recommendation status: Yes. Hiring a State EMS Medical Director is the single most emphasized recommendation, appearing in both Regulation and Policy and Medical Direction sections. The TAT states it "may be the highest priority."
3I. Communications and Infrastructure
(a) Direct quotes:
"many dispatch centers continue to operate without standardized emergency medical dispatch training"
"There are no requirements for dispatch centers accepting medical emergency calls to have medical priority dispatch systems"
"There are no requirements for PSAPs to utilize certified EMDs. There are no required EMD training standards or certification standards."
"The lack of a comprehensive EMD system statewide is a disservice to the residents of Iowa."
"there are 117 public safety answering points (PSAP) across 99 counties"
"not all PSAPs have computer-aided dispatch systems"
(b) Specific data points:
- 117 PSAPs across 99 counties
- Enhanced 911 implemented statewide (landline and wireless Phase II)
- Next Generation 911 system under development (target completion December 31, 2015)
- Text-to-911 capability in development for "select PSAPs"
- EMS communications directory updated 2002
- Statewide Communications Interoperability Plan (SCIP) developed August 2013 — "many goals, but no implementation plan"
- No EMD certification standards
- No EMD training standards
- No medical direction requirements for EMD
- No EMS representation on state Interoperability Board (statute change needed)
- CAD-to-ePCR auto-population: available where CAD exists; others email data after call closure
- FirstNet consultation participation noted
(c) Report characterization: The TAT characterizes the absence of statewide EMD as "a disservice to the residents of Iowa." The 117 PSAPs across 99 counties are described as lacking consistency in EMS response.
(d) Priority recommendation status: Yes. EMD legislation, PSAP regionalization, interoperability board representation, and communications system upgrade are all recommended to the legislature.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
The report does not include a formal "Progress on Prior Recommendations" section. References to the prior assessment are incidental:
"Since the last NHTSA assessment, BETS has been able to establish standards and authorize all non transport services including air and ground ambulance service programs." (Transportation)
"Since the last NHTSA assessment, Iowa updated the EMS communications directory in 2002" (Communications)
The prior assessment year is not explicitly stated. The trauma system plan dates to 1994 and trauma system implementation to 2001, but these are not tied to the prior assessment date.
No systematic accounting of prior recommendation completion status is provided.
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall System Characterization
"The sense of pride and service that built Iowa is clearly evident in the volunteer and career EMS caregivers and the myriad of nurses, physicians, and other health care providers that care for the residents of Iowa."
"This office is staffed with individuals who have a stunning level of commitment to the profession of emergency care. Many of these individuals have worked to grow and improve EMS and emergency care in Iowa for decades, longevity that is seldom enjoyed or seen elsewhere in our country."
"The system that is in place, and the improvements made along the way, are a testament to the dedication and hard work of the past."
"The TAT is confident that the new division leadership, combined with an experienced and remarkably dedicated bureau staff and statewide cadre of healthcare providers, will make the future Iowa EMS, trauma, and stroke/STEMI care system an example of success to which other states will strive to match."
The introduction uses a literary framing celebrating Iowa's history, culture, and service tradition. The tone is notably warm and optimistic, more so than the Kentucky or Georgia reports.
Structural Barriers Identified
1. No EMS regions — the most pervasive finding, appearing in virtually every section
2. No State EMS Medical Director — vacant "for a number of years," characterized as potentially "the highest priority"
3. No essential service designation — EMS not a statutory responsibility of any local government
4. 99-county fragmentation — 931 service programs, 117 PSAPs, no multi-county coordination
5. Declining volunteerism — aging rural workforce, "unlikely to abate"
6. Inadequate funding — $830,000 after grants for all non-grant activities
7. No statewide EMD — "a disservice to the residents of Iowa"
8. Outdated trauma plan — 1994 plan, "slow" maturation since 2001
9. Data quality concerns — non-transport agencies not reporting, paper charts still in use
10. Protocol omission paradox — medical directors can omit statewide protocol elements while theoretically required to meet or exceed them
Transportation vs. Healthcare Framework
The report is sponsored through NHTSA highway safety funding, and the background section focuses heavily on traffic fatalities and CDC crash injury costs. However, the TAT frames EMS as a healthcare system:
"BETS was formed in 2014, when the former Bureau of EMS and the Center for Disaster Operation and Response were merged"
The lead agency placement within the Department of Public Health is documented without commentary (unlike Georgia, where the TAT explicitly endorsed the DPH placement).
Federal Funding Mechanisms Referenced
- Highway Traffic Safety grant
- HPP and PHEP CDC grants
- EMSC grant
- Federal Block grant
- Flex grant
- EMS System Development Grants (state legislative allocation + certification fees + commemorative certificate revenue)
Greatest Strengths (as identified by the TAT)
- Staff longevity and dedication — "stunning level of commitment," "decades" of service
- Inclusive trauma system with all 118 hospitals participating
- CAAHEP accreditation of paramedic education programs
- EMS System Standards Self-Assessment Tool (52 standards)
- Robust EMS for Children program (pediatric equipment distribution, Love Our Kids grants)
- 36% of ALS/BLS providers carry ALL nationally recommended pediatric equipment (above national average)
- Strong preparedness program (EMAC participation, healthcare coalitions, HPP/PHEP grants)
- Peer-review data protected by statute
- Next Generation 911 development
- E911 Phase II statewide
- New BETS leadership combined with experienced staff
Most Critical Challenges (as identified by the TAT)
- No State EMS Medical Director — "may be the highest priority"
- No EMS or trauma regions — "near universal calls for regionalization"
- EMS not an essential service — not a statutory responsibility of any government level
- 931 service programs overseen by 4 regional coordinators
- Declining volunteerism in rural areas
- Outdated trauma system plan (1994)
- 93 Level IV trauma centers with undifferentiated capabilities
- 1.3 FTE dedicated to trauma system
- No EMD system statewide
- No interfacility transfer protocols
- Unknown preventable trauma mortality
- Protocol omission by medical directors
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
Regionalization as Universal Theme
The absence of formal EMS or trauma regions is the dominant finding of this report, appearing in Regulation and Policy, Resource Management, Transportation, Communications, Medical Direction, Trauma Systems, Evaluation, and Preparedness sections. The TAT notes:
"There was near universal calls for regionalization of EMS and trauma activities by presenters."
Prior regionalization had been attempted through public health/preparedness but "abandoned when they were not found to be effective." The TAT recommends building new regions around trauma referral patterns.
"Dizzying" Agency Count
"There is a dizzying number of EMS agencies; 333 fully certified ambulance agencies, 144 agencies certified as 'transport agreement' agencies, and 436 non-transporting agencies."
The total of 931 authorized service programs overseen by 4 regional coordinators (inspecting every 3 years) represents one of the most extreme ratios documented in the NHTSA assessment corpus.
Highest Priority Designation
"This may be the highest priority for the BETS at this time."
The TAT's explicit prioritization of the State EMS Medical Director position above all other recommendations is unusual. Most NHTSA reports present recommendations without explicit ranking.
Essential Service — Most Direct Statement
"Iowa does not have the provision of EMS as a statutory responsibility of counties, townships or cities, leading to the common issue of EMS not being seen as an essential service, which the public most certainly expects."
This is among the most direct and clearly articulated statements on essential service designation in the corpus. It explicitly connects the statutory gap to public expectation.
Paradigm Reversal in Trauma Philosophy
"the paradigm should be reversed to say the goal is 'to provide medical resources required to meet existing patient needs'"
The TAT's recommendation to shift from matching patients to resources to matching resources to patients represents a significant conceptual evolution in trauma system philosophy. This framing distinguishes between a system designed around existing capacity and one designed around patient needs.
Protocol Omission Paradox
"medical directors are allowed to omit portions of the statewide protocols. This practice appears to contradict the requirement of meeting or exceeding the minimum standard of care"
This internal contradiction in the regulatory framework — allowing omissions from a minimum standard — is explicitly identified by the TAT as problematic.
Level IV Undifferentiation
93 Level IV trauma centers with varying capabilities represent a significant triage challenge. The TAT recommends Level V designation to differentiate among these, noting:
"Level IV trauma centers in adjacent counties, despite each meeting state requirements, may have very different capabilities."
This parallels findings in other rural states but the scale (93 undifferentiated centers) is notable.
30-Minute Triage Threshold
The current triage protocol allows bypass to Level I/II only if within 30 minutes. The TAT explicitly challenges this:
"In many cases, it would minimize morbidity and mortality to transport the patient to a Level I or II trauma center 45 or 60 minutes away - rather than to a closer hospital without emergency surgical capability."
Love Our Kids License Plate Program
"Revenues are generated from a vanity license plate to provide pediatric injury prevention projects through a grant process for rural Iowa communities."
At approximately $30,000/year with $1,500 per applicant, this is a small but distinctive funding mechanism.
Multi-Level Paramedic Designation
BETS was in the process of eliminating multiple paramedic levels, which the TAT characterizes as "extremely positive" and notes the previous system was "confusing."
No Billing Standardization
"Many service programs do not bill for their services instead relying upon taxpayer support."
The absence of billing by some agencies, combined with no statewide fee structure, creates both overbilling and underbilling risks.
Prior Assessment Year Unknown
Unlike other reports in the corpus, the Iowa reassessment does not specify the year of the prior assessment. References to the "last NHTSA assessment" appear without a date, making longitudinal comparison more difficult.
Volunteer Discount Economy
"Some local governments have long received EMS at a huge discount due to the dedication of the volunteers in rural areas. Now that this resource is shrinking, local governments have difficulty finding funds to continue the provision of this critical safety net service."
This observation explicitly connects the volunteer model's decline to a looming funding crisis — the true cost of EMS was being absorbed by volunteers rather than funded by government.
Analysis completed per standardized NHTSA State EMS Assessment framework. No synthesis or editorial interpretation has been applied. Findings are extracted as documented in the report.
Kansas
Full Analysis
Kansas 2007 NHTSA EMS Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Kansas
- Report type: Reassessment
- Date of site visit: July 17–19, 2007
- Year of publication: 2007
- Prior assessment year: 1994
- TAT members:
- David W. Bryson (EMS Specialist, NHTSA — served as NHTSA facilitator)
- Bill Jermyn, DO, FACEP (State EMS Medical Director, Bureau of EMS, Missouri Department of Health)
- W. Dan Manz (Director, Emergency Medical Services Division, Vermont Department of Health)
- Stuart A. Reynolds, MD, FACS (General Surgeon, Northern Montana Hospital; Chair, Montana EMS Advisory Council)
- P. Scott Winston (Assistant Director, Virginia Department of Health, Office of Emergency Medical Services)
- NHTSA facilitator: David W. Bryson, EMS Specialist, NHTSA
- Number of presenters/briefings: Over 35 presenters from the State of Kansas (p. 2)
- Requesting agency: Kansas Board of Emergency Medical Services (KBEMS), in concert with the Kansas Department of Transportation's Bureau of Traffic Safety (p. 1–2)
SECTION 2: STATE CONTEXT
- Population (as cited in report): Almost 3 million people (p. 5)
- Geographic characteristics: 81,815 square miles, making it the 15th largest state in the nation. Bordered by Nebraska (north), Missouri (east), Oklahoma (south), and Colorado (west). Approximately 71% of Kansans reside in urban clusters. A significant portion of counties are classified as rural or frontier. (p. 5)
- Number of counties/jurisdictions: 105 counties and 627 incorporated cities (p. 5)
- EMS system overview:
- Governance structure: KBEMS is a board with 13 members and a Chief Administrator (pp. 5, 7). The Kansas Department of Health and Environment (KDHE) administers the trauma system separately (p. 27). KBEMS has regulatory authority for certification of attendants and instructor/coordinators, approval of training programs, and licensure of services and vehicles — but lacks authority over multiple other EMS system components (p. 7–8).
- Number of agencies/providers: Approximately 11,000 certified EMS personnel; 170 licensed ambulance services (later stated as 173); 7 air ambulance services; 856 ambulance vehicles (later stated as 648 vehicles); 125 hospitals including 83 Critical Access Hospitals (pp. 10, 16)
- Notable demographic or socioeconomic factors cited: The report notes the rural/frontier character of a significant portion of the state and the concentration of 71% of population in urban clusters, creating a resource distribution challenge (pp. 5, 10–11).
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:There is still no formalized statewide EMS plan which addresses the needs of the EMS system. The Strategic plan appeared to be a plan for the Board and has little to do with the overall development of the Kansas EMS system." (p. 8)
The current KBEMS plan describes a vision for Board operations but does not adequately address the State's EMS system." (p. 12)
In the absence of a process for centrally coordinating EMS resources, EMS organizations have evolved in size and number apparently in response to local demands and commitments of funding rather than in response to any uniform identification of need." (p. 10–11)
no statewide transportation plan exists." (p. 16)(b) Specific data points: The 2005 KBEMS strategic plan was provided to the TAT but characterized as a board operations plan, not a system plan (p. 8). (c) Report characterization: The TAT characterizes the absence of a statewide EMS plan as a significant gap, directly tied to the inability to manage resources, evaluate the system, or ensure equitable service distribution. (d) Priority recommendation: Yes (bolded):
KBEMS must develop a statewide EMS plan which includes details about the characteristics and capabilities of the EMS system." (p. 12)
3B. Funding and Financial Sustainability
(a) Direct quotes:The Kansas legislature recently established an EMS enhancement grant to provide funding to EMS regional councils and ambulance services to purchase necessary equipment, supplies, and support EMS with specialized training programs." (p. 14)
Kansas has an Education Incentive Grant program to defray the cost of EMS training for volunteer EMS personnel." (p. 14)
Legislatively, a dedicated funding source has been instituted based on a small percentage of Kansas court docket fees" (p. 28) — this pertains specifically to trauma system funding.
On a number of occasions testimony reflected the need for funding to improve the access and availability of specialty training programs" (p. 14)(b) Specific data points: No specific dollar amounts for KBEMS budget, state EMS appropriations, or the enhancement grant program are cited. The court docket fee funding source for the trauma system is noted but not quantified. The TAT recommends the enhancement grant funds be "earmarked for training" (p. 14). (c) Report characterization: The report identifies funding needs across multiple sections but does not characterize the overall state EMS funding as adequate or inadequate in a single summary statement. The trauma system is identified as needing "additional dedicated funding" (p. 28). The establishment of the EMS enhancement grant is noted as a positive development. (d) Priority recommendation: The trauma section contains a bolded recommendation to "seek additional dedicated funding" for trauma center development, designation, and regional council support (p. 28). No overarching bolded recommendation addresses the state EMS budget.
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:There remains a perceived shortage of EMS personnel throughout Kansas. Some testimony suggested this is due to low salaries. No formal needs assessment has ever been performed to determine actual staffing requirements for the system." (p. 15)
Approximately 55% of certified EMS personnel are not affiliated with an ambulance service." (p. 15)
Throughout much of Kansas there is a perceived shortage of EMS personnel." (p. 17)
Ambulance service managers reported long distance interfacility transfers place a burden on local squads working to maintain 9-1-1 coverage." (p. 15)
Staffing shortages at rural hospitals are expanding the expectations of rural EMS providers as they are more involved in patient care while in the emergency department." (p. 15)
Several presenters spoke about the need to recruit and retain a more robust EMS workforce. This need was identified across the spectrum of volunteer and career ambulance services operating in both rural and urban settings." (p. 11)(b) Specific data points:
- 11,000 certified attendants as of July 2007, up from approximately 9,200 in 1994 (p. 13)
- By level: 1,025 first responders; 6,214 EMTs; 1,138 EMT-Is; 82 EMT-Ds; 1,929 MICTs; 192 instructor/coordinators; 523 training officers I and II (p. 13)
- 55% of certified personnel are not affiliated with an ambulance service (p. 15)
- An unknown number of certified personnel are associated with "industrial brigades (manufacturing, oil refinery, etc.)" (p. 15)
3D. Essential Service Designation
(a) Direct quotes: Not documented in this report. The phrase "essential service" does not appear. The report does not discuss whether Kansas legally designates EMS as an essential service. (b) Specific data points: None. (c) Report characterization: N/A. (d) Priority recommendation: The report does not recommend essential service designation.3E. Regulatory Fragmentation
(a) Direct quotes:KBEMS does not have statutory authority to regulate all components of the EMS system including 9-1-1 dispatch centers, certification of dispatchers, medical oversight for dispatch centers, licensing of non-transporting agencies, approval of protocols and scopes of practice, instruction and approval of instructor coordinators and specific regulations for air ambulance services." (p. 7–8)
KBEMS lacks the statutory authority to categorize, organize, and deploy resources across Kansas for intra and inter state response to disasters." (p. 8)
Non-transporting EMS agencies are an important EMS response resource which is currently outside of EMS regulation." (p. 11)
Most glaring as a deficiency in the system is the ability of any physician, regardless of specialty, licensed to practice in Kansas, not only having the ability to serve as a medical director for an ambulance service but also having the power to authorize any individual to provide patient care regardless of training or background." (p. 8)
KBEMS has no authority to enforce an EMS scope of practice, monitor the field personnel's standard of care, or assure the health and safety of the citizens of Kansas." (p. 8)
KBEMS appears to have a dedicated staff...Despite their efforts, progress has been modest." (p. 7)
The task of leading EMS change in Kansas is not clearly assigned to anyone." (p. 5)
KBEMS lacks the necessary desire, strength and unified vision to lead the EMS system in Kansas." (p. 8)(b) Specific data points:
- KBEMS has regulatory authority over only a subset of EMS system components (certification, training programs, ambulance licensure) (p. 7–8)
- Non-transporting agencies are completely unregulated (p. 11)
- No authority over dispatch centers, dispatcher certification, or protocol/scope of practice approval (p. 7–8)
- Only 2 of 13 KBEMS board members were present during testimony (p. 5)
- Trauma system is administered separately by KDHE (p. 27)
The Governor and Legislative leadership must monitor progress towards KBEMS publicly performing their role as the lead EMS agency and directing staff in the regulation and management of the EMS system in Kansas or reorganize KBEMS to serve in an advisory capacity to the Chief Administrator." (p. 9)
KBEMS must develop and implement regulations for licensing of non-transporting agencies." (p. 9)
KBEMS must abolish the independent ability of a licensed physician to institute protocols which exceed the EMS personnel's authorized scope of practice." (p. 9)
3F. Data and Evaluation Systems
(a) Direct quotes:The lack of information is significantly hampering the efforts of the KBEMS and local EMS services in evaluating the effectiveness and safety of their systems." (p. 30)
It is hoped the Kansas Emergency Medical Information System (KEMIS) program will significantly help alleviate this dearth of data." (p. 30)
One identified area of potential improvement was in linking the trauma system database with the KEMIS data." (p. 31)
Both proposed systems are too new or under development and it is too early to make any reasonable assessment of their effectiveness." (p. 31)(b) Specific data points:
- The state data system is the Kansas Emergency Medical Information System (KEMIS), which was under implementation at the time of the reassessment (p. 30)
- No NEMSIS version is cited
- Trauma registry data is being collected by "almost every hospital in Kansas" (p. 31)
- Trauma registry provides quarterly feedback with 10 registry-generated indicators (p. 28)
- No linkage between prehospital data and hospital outcomes exists (p. 31)
KBEMS must continue with the implementation of a statewide electronic incident reporting system. This system is essential to obtaining the data which will support system evaluation." (p. 11)
KBEMS must continue the QI training sessions for both service administrative personnel and for medical advisors." (p. 31)
3G. Trauma System Status
(a) Direct quotes:At the time of the 1994 Technical Assessment Team visit there was not a Trauma System, State Designation of Trauma Centers, a statewide Trauma Registry, essentially no prehospital trauma triage criteria and trauma patient death autopsies were not mandated." (p. 27)
In 1999, legislation was passed initiating the system by creating the Kansas Advisory Committee on Trauma (ACT) and its associated six Regional Trauma Advisory Councils, designating the KDHE as the administering agency, and implemented a statewide Trauma Registry." (p. 27)
By 2001, the ACT had developed the Kansas Trauma Plan, instituting an inclusive, voluntary system, delegating most development activities to the Regional Councils." (p. 27–28)
Legislatively, a dedicated funding source has been instituted based on a small percentage of Kansas court docket fees" (p. 28)
The lack of surgical manpower coverage in two of the potential level IIIs may be problematic for designation." (p. 28)(b) Specific data points:
- 3 ACS-verified Level I trauma centers, 1 Level II, 1 Level III (p. 10, 28)
- 2 American Burn Association certified burn centers (p. 28)
- 5 additional hospitals planned for Level III designation, one in each of the remaining 5 EMS regions (pp. 18, 28)
- 6 Regional Trauma Advisory Councils (p. 27)
- 11–12 ATLS courses offered annually (p. 28)
- 10 registry-generated indicators analyzed quarterly (p. 28)
- Trauma system established 1999; Kansas Trauma Plan developed 2001 (pp. 27–28)
- Dedicated funding from Kansas court docket fees (p. 28)
- Trauma registry participation by all but 2 hospitals (p. 28)
3H. Medical Direction
(a) Direct quotes:Since the 1994 assessment, little progress has been made in the evolution of the medical advisor role." (p. 24)
The Governor appointed a KBEMS medical advisor; however, this position has limited influence on the quality of care provided within the EMS system." (p. 24)
The MA is not required to have an EMS knowledge base." (p. 24)
The local MA may expand the State authorized scope of practice for the personnel functioning under their license. Coupled with the lack of specific EMS knowledge of many MAs, this establishes a model where the scope of practice of some personnel appears to exceed generally accepted safeguards and principles." (p. 24)
Local medical societies or hospital staffs are required to approve medical protocols proposed by the MA. This seems a cumbersome system which has the potential for significant conflict between two factions who may have diverse goals and subject knowledge." (p. 25)
No formal training mechanism for MAs is currently available for those who are interested. The Medical Advisor's course was presented last in 1999, and seems to have lost momentum." (p. 25)
From the 1994 NHTSA assessment, 'There is no communication between the MAs and the KBEMS regarding responsibilities of the MA, information regarding Kansas EMS, and activities of KBEMS.' This appears unchanged today." (p. 25)
There is no requirement for non-transporting agencies in their provision of care or dispatch agencies providing pre-arrival instructions, for a medical advisor to oversee their practice of medicine." (p. 25)(b) Specific data points:
- Medical Advisor course last offered in 1999 (p. 25)
- No formal training mechanism currently available (p. 25)
- The Governor has appointed a KBEMS medical advisor, but the position has "limited influence" (p. 24)
KBEMS must institute the recommendation of the 1994 TAT which was, 'Redefine the medical Consultant position as the State EMS Medical Director for the KBEMS. Roles and responsibilities for the medical director should be developed, including medical input into protocols and all issues related to the care of EMS patients. The medical director should serve as a medical resource and provide leadership to local EMS medical directors.'" (p. 25)
KBEMS must abolish the provision of local medical societies or hospital staffs having approval authority over EMS protocols." (p. 26)
KBEMS must require all patient care to be supervised by an MA. All EMS agencies, regardless of transporting status, must have a qualified MA." (p. 26)
3I. Communications and Infrastructure
(a) Direct quotes:Since the 1994 assessment, little has changed in the structure of the Kansas EMS communications network." (p. 20)
EMS radio communication in Kansas is not a statewide system but rather a patchwork of many local subsystems." (p. 20)
These local subsystems break down when there is a need to coordinate EMS resources from outside the area which operate on different radio spectrums." (p. 20)
All presenters agreed a single system solution was unlikely to work given the cost of replacing existing infrastructure." (p. 21)
There remains no requirement in Kansas for the training of EMS dispatchers or medical oversight in the provision of pre-arrival instructions." (p. 20)(b) Specific data points:
- All of Kansas except 1 county has 9-1-1 coverage (p. 20)
- Growing percentage of the state has E-9-1-1 and wireless E-9-1-1 (p. 20)
- KDOT developing an 800 MHz trunked radio system (p. 21)
- No count of PSAPs or dispatch centers is provided
- No statewide dispatacher training or certification exists (p. 20)
- The northwestern region created a common VHF system among participating counties (p. 21)
KBEMS must establish training and certification requirements for EMS dispatchers and the medical oversight of pre-arrival instructions." (p. 21)
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (Reassessment)
The report explicitly measures progress since the 1994 assessment across each component area. No formal numbered tracking of prior recommendations is provided, but the report characterizes progress narratively for each section.
Overall characterization of progress since 1994:Since an original EMS system assessment in 1994, thirteen years have passed with predominantly cosmetic changes to the system." (p. 5)Section-by-section progress characterization:
- Regulation and Policy: "While Kansas Statute 65-6102 establishes the KBEMS as the lead EMS agency in Kansas, there appear to be many holes in the current design which weakens the overall system." (p. 7) — No major structural change.
- Resource Management: "Since the 1994 assessment, little progress has been made in the area of resource management." (p. 10)
- Human Resources: Personnel count increased from 9,200 to 11,000 since 1994. NREMT reinstated. Recertification changed from 1 year to 2 years. Full-time Education Manager hired. (pp. 13–14)
- Transportation: Decrease in total number of ambulance services since 1994, but "testimony provided to the TAT suggested a better coverage pattern for the system despite this loss" (p. 16).
- Facilities: "To a great degree, the recommendations of the 1994 TAT have been addressed." (p. 18) — Characterized as the area of most progress outside of trauma.
- Communications: "Since the 1994 assessment, little has changed in the structure of the Kansas EMS communications network." (p. 20)
- Public Information/Education/Prevention: "Little has been done to address the recommendations made in the 1994 assessment report." (p. 22)
- Medical Direction: "Since the 1994 assessment, little progress has been made in the evolution of the medical advisor role." (p. 24) The 1994 recommendation for a State EMS Medical Director is explicitly quoted and re-recommended (p. 25).
- Trauma Systems: Substantial progress — from no trauma system in 1994 to a legislatively established system with ACS verification, regional councils, trauma registry, and dedicated funding (pp. 27–28). This is the area of greatest documented progress.
- Evaluation: KEMIS under implementation. "Both proposed systems are too new or under development" (p. 31).
- Substantial in 2 areas (Trauma Systems, Facilities)
- Modest/incremental in 2 areas (Human Resources, Transportation)
- Little or no progress in 6 areas (Regulation and Policy, Resource Management, Communications, Public Information/Education/Prevention, Medical Direction, Evaluation)
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization:The tone of this report is measured but pointed. The TAT avoids the dramatic language seen in some reassessments but delivers a clear message about institutional underperformance:
hirteen years have passed with predominantly cosmetic changes to the system." (p. 5)
The task of leading EMS change in Kansas is not clearly assigned to anyone." (p. 5)
KBEMS lacks the necessary desire, strength and unified vision to lead the EMS system in Kansas." (p. 8)
During a day and a half of testimony to the technical assistance team (TAT), only two of thirteen KBEMS board members were present at any time to hear the outlooks, opinions, hopes and aspirations for the system which KBEMS oversees." (p. 5)
The Lee Iacocca quote — "Lead, follow, or get out of the way" — is deployed as a direct challenge to the KBEMS board (p. 5).
The report's closing framing is cautiously optimistic:
The assessment team identified no fatal flaws which cannot be corrected through leadership, consensus, cooperation, resources, and an organizational structure that follows through until the job is done." (p. 6)
A world class EMS system? The dream is not too big for Kansas." (p. 6)Structural barriers identified:
- Statutory gaps in KBEMS authority (dispatch, non-transporting agencies, scope of practice, air ambulance, disaster deployment) (pp. 7–8)
- Board disengagement (2 of 13 members present for testimony) (p. 5)
- Any licensed physician can serve as medical advisor and expand scope of practice without oversight (p. 8)
- Medical societies hold veto power over EMS protocols (p. 25)
- Trauma system administered by KDHE separately from the EMS lead agency (p. 27)
- Non-transporting agencies completely unregulated (p. 11)
The report operates within the transportation framework. The reassessment was requested through the Kansas Department of Transportation's Bureau of Traffic Safety (p. 1–2). The Background section references highway safety funds (p. 1). The report references the "1996 EMS Agenda for the Future" and its vision of a "comprehensive and integrated health management system" (p. 1), but the recommendations do not operationalize a healthcare integration framework.
Federal funding references:The Background section references NHTSA highway safety funds as supporting the assessment program (p. 1). The Communications section notes "A significant amount of federal funding is available if an appropriate plan can be written quickly" for interoperability (p. 21). The Domestic Preparedness section references increased participation in "Homeland Security planning activities and funding requests" (p. 32). No Section 402 funds are cited by name.
Greatest strengths (as identified by the TAT):he TAT was impressed with the knowledge, dedication, and spirit of the presenters." (p. 6)
There are components of the EMS system, trauma care as one example, where progress is occurring and there appears to be momentum in a positive direction." (p. 6)
The trauma system development is the single most positively characterized element, having been built essentially from scratch since 1994 (pp. 27–28).
The KBEMS staff is described as "very dedicated" with "a mix of experience and institutional memory with the energy and intellectual curiosity of recent converts to the cause" (p. 5).
The MERGe disaster response initiative is called "admirable" (p. 11).Most critical challenges (as identified by the TAT):
- Board disengagement and lack of leadership vision (pp. 5, 8)
- Statutory gaps leaving KBEMS unable to regulate all EMS system components (pp. 7–8)
- Absence of a statewide EMS plan (pp. 8, 12)
- No formal State EMS Medical Director with actual authority (pp. 24–25)
- Any physician can expand scope of practice without EMS knowledge or oversight (p. 8, 24)
- Non-transporting agencies unregulated (pp. 9, 11)
- Patchwork communications with no dispatcher training requirements (pp. 20–21)
- Dearth of data for system evaluation (p. 30)
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. Board disengagement documented quantitatively
The fact that only 2 of 13 KBEMS board members attended any portion of the TAT testimony (p. 5) is a striking data point. The TAT's choice to document this in the Introduction — the most prominent section of the report — signals that the board's absence was interpreted as indicative of the leadership vacuum.
2. "Cosmetic changes" characterization
The phrase "predominantly cosmetic changes" to describe 13 years of progress (p. 5) is distinctive. While less dramatic than the Oregon 2006 reassessment's "dramatic deterioration," it conveys a comparable finding: structural stagnation despite the passage of time and a prior assessment.
3. Any physician can authorize anyone to provide patient care
Most glaring as a deficiency in the system is the ability of any physician, regardless of specialty, licensed to practice in Kansas, not only having the ability to serve as a medical director for an ambulance service but also having the power to authorize any individual to provide patient care regardless of training or background." (p. 8)
This finding is unusual in the NHTSA assessment corpus. The report identifies this as the "most glaring" deficiency, characterizing it as a fundamental public safety gap.
4. 55% non-affiliation rate
Approximately 55% of certified EMS personnel are not affiliated with an ambulance service." (p. 15)
This is a remarkably high non-affiliation rate. The report notes an unknown number of these personnel are associated with industrial brigades, but the implication is that a majority of certified personnel are not actively serving in the ambulance response system.
5. Ultimatum to KBEMS
The TAT presents a binary choice to the board:
KBEMS must either publicly perform their role as the lead EMS agency, directing staff in the regulation and management of the EMS system in Kansas or be reorganized to serve in an advisory capacity to the Chief Administrator who would report directly to the Governor." (p. 8–9)
This ultimatum structure — perform or be replaced — is uncommon in NHTSA reassessments and reflects the severity of the TAT's assessment of board performance.
6. 1994 recommendation explicitly re-recommended verbatim
The TAT quotes the 1994 recommendation for a State EMS Medical Director and re-recommends it 13 years later with the word "must":
KBEMS must institute the recommendation of the 1994 TAT which was, 'Redefine the medical Consultant position as the State EMS Medical Director for the KBEMS.'" (p. 25)
This explicit recycling of a prior recommendation with escalated urgency language is a notable technique indicating frustration with non-implementation.
7. Trauma system as positive outlier
The trauma system stands in sharp contrast to the rest of the Kansas EMS system. Between 1994 and 2007, the state went from no trauma system to a legislatively established, inclusive, voluntary system with ACS verification, 6 regional councils, a statewide registry, dedicated funding, and quarterly feedback on 10 indicators. This progress occurred under KDHE administration — separate from KBEMS — which may itself be a notable finding regarding institutional capacity.
8. Medical societies holding protocol approval authority
Local medical societies or hospital staffs are required to approve medical protocols proposed by the MA." (p. 25)
The TAT recommends abolishing this provision (p. 26). This structural arrangement — where a medical society or hospital staff can override EMS medical director protocols — is unusual and identified as a barrier to effective medical direction.
9. Discrepancy in vehicle/service counts
The report cites 170 licensed ambulance services and 856 ambulance vehicles in one section (p. 10) and 173 services with 648 vehicles in another (p. 16). This internal inconsistency may reflect different data sources or time frames, but it also illustrates the data challenges documented elsewhere in the report.
10. Rural hospital staffing expanding EMS provider roles
Staffing shortages at rural hospitals are expanding the expectations of rural EMS providers as they are more involved in patient care while in the emergency department." (p. 15)
This finding anticipates a trend that would become more prominent in later state assessments nationally — the blurring of EMS and emergency department roles in rural settings driven by healthcare workforce shortages.
Analysis extracted by standardized framework. No editorial synthesis applied. All page references correspond to the PDF pagination of the source document.
Kentucky
Greatest Strengths
- Board establishment as a single lead agency (2000)
- NEMSIS v3.5 transition — "a notable and worthy achievement"
- EMSC Program active since 1996 with generally high participation
- Traffic Incident Management (TIM) implementation — Board "commended for its continued dedication and successful implementation"
- Advanced Practice Paramedic (APP) licensure development
Most Critical Challenges
- No comprehensive statewide EMS plan (unfulfilled since 1991)
- EMS not designated as an essential service
- Inadequate and unsustainable funding
- Paramedic workforce shortage, particularly in rural areas
- Unfunded trauma system with injury mortality "far higher than in other states"
Full Analysis
Kentucky 2024 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Commonwealth of Kentucky
- Report type: Reassessment
- Date of site visit: November 19–21, 2024
- Year of publication: 2024
- Prior assessment year: 1991
- TAT members:
- Curtis C. Sandy, MD, FACEP, FAEMS
- Mark Gestring, MD, FACS
- Alisa Habeeb Williams, NRP, B.S.
- Jason M. Rhodes, MPA, AEMT-C
- NHTSA facilitator: Dave Bryson
- Executive Support: Susan Wiczalkowski
- Number of presenters/briefings: Not specified by count. The report states:
he team thanks all the presenters for being candid and open regarding the status of emergency medical services in Kentucky.
- Requesting agency: Kentucky Transportation Cabinet (KYTC) / Kentucky Office of Highway Safety (KOHS), in collaboration with the Kentucky Board of EMS
SECTION 2: STATE CONTEXT
- Population (as cited in report): 4,505,836 (Census 2020)
- Geographic characteristics:
a primarily rural state, is the 37th largest state in land area, encompassing 39,492 square miles with a population density of 114.1 persons per mile
bordered by seven states and situated in the Upland South with a significant portion of eastern Kentucky being located in Appalachia
a varied climate and diverse topography which includes six distinct geographical regions and the greatest length of navigable waterways and streams in the contiguous United States
- Number of counties/jurisdictions: 120 counties
- EMS system overview:
- The Board exercises:
all of the administrative functions of the State in the regulation of the emergency medical services system and the practice of first responders, emergency medical technicians, paramedics, ambulance services, and training institutions
- 190 Class 1 ground agencies provide ALS care to 119 of 120 counties
- The trauma system is housed within the Kentucky Hospital Association (KHA), not the Board
- Complaint investigation at the EMS agency level is delegated to the Office of Inspector General within the Cabinet for Health and Family Services — not the Board
- Notable demographic or socioeconomic factors cited:
- Mean annual salary: $54,200
- Median annual salary: $43,300
- Poverty rate: 16%
- Uninsured rate: 6%
Kentucky's socioeconomic status is challenging
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:A comprehensive plan has not been implemented.
It is reported that nearly all comprehensive emergency medical services system planning occurs locally by elected officials and their staff.
Besides KRS 311A, which requires the Board to develop a statewide plan for implementing an emergency medical services system, there is no requirement or mechanism to conduct state-level comprehensive EMS system planning within the Commonwealth.
Due to the time since the last evaluation, numerous personnel changes, and changes in overall agency location, it is unknown if a total EMS evaluation of the entire system has ever been completed.
The current staff does not know of any documents or processes from the past that would indicate any formal action on this system-wide assessment.(b) Specific data points:
- 33 years elapsed between the original 1991 assessment and this 2024 reassessment
- KRS 311A requires the Board to develop a statewide plan, but no plan has been produced
- Planning occurs at the local level only
3B. Funding and Financial Sustainability
(a) Direct quotes:he system is not funded to the level needed
Kentucky has made a commendable effort in the provision of State funding to support the statewide EMS system. Unfortunately, the system is not funded to the level needed.
local EMS agencies rely on local tax revenue, reimbursement for services from insurance providers, or a fee-for-service model to meet operational costs
While the Board disburses grant funding to fiscal courts in the amount of $10,000 annually, the funds are not guaranteed annually or administered to every fiscal court.
The Commonwealth of Kentucky provides no other direct grant funding opportunities for EMS operations.
No dedicated funding programs were ever implemented or exist under State legislation to provide flexibility in the current funding programs.
he annual block grant has not been adjusted in its annual amount since its inception and only provides a limited amount of funds
The Board is a regulatory and compliance organization and does not provide education opportunities directly. The Board does not receive funding to offer education, retention, or incentives.(b) Specific data points:
- Board biennium budget (FY2025): $2,600,000 in general funds + $650,000 in annual licensure fees
- Federal EMSC funding: $174,300
- Block grant to fiscal courts: $10,000 annually (not guaranteed; not adjusted since inception)
- Trauma system: unfunded since the 2008 Kentucky Trauma Care Law was passed
- One staff member (State Trauma Director) funded indirectly through a short-term preparedness grant
- CARES initiative: in early stages, coordination and funding needed
- 2024 EMS training grant program enacted by General Assembly: unfunded
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:Like many other States, the Commonwealth is experiencing a substantial workforce shortage at the paramedic level.
Twenty-one authorized and accredited paramedic education programs produce, on average, 130 new paramedics annually.
With nearly one-third of these new clinicians staying in metro areas, the rural areas of Kentucky are not producing or hiring enough paramedics.
here are some counties experiencing significant delays in response and paramedic staffing shortages. These result in agencies operating at the BLS level in some instances.
Kentucky currently has no volunteer services in operation.
he Kentucky General Assembly enacted a new EMS training grant program during the 2024 regular session. It remains an unfunded project.(b) Specific data points:
- 21 accredited paramedic education programs
- ~130 new paramedics produced annually
- ~1/3 of new paramedics remain in metro areas
- 119 of 120 counties have ALS coverage, but with staffing gaps
- Zero volunteer EMS services in operation (fire service volunteers respond under first response programs not under Board authority)
- Workforce committee established 2024 — described as "in its infancy"
3D. Essential Service Designation
(a) Direct quotes:Emergency medical services has not been codified in State statute as an essential service in the Commonwealth of Kentucky
here is also no legislation designating EMS as an essential service
Kentucky's EMS agencies are considered non-essential.
he large majority of local jurisdictions do provide EMS, but the level of care and timeliness of response varies(b) Specific data points:
- EMS is not designated as an essential service in Kentucky statute
- The recommendation to "Define EMS as an essential service with sustainable funding mechanisms" appears in at least 3 sections: Regulation and Policy, Resource Management, and Transportation
- Regulation and Policy Recommendations ("Define EMS as an essential service with sustainable funding mechanisms")
- Resource Management Recommendations ("Statutorily codify EMS as an essential service in the Commonwealth of Kentucky, with provisions to enhance funding to local EMS agencies to provide timely and consistent emergency medical care and transportation")
- Transportation Recommendations ("Define EMS as an essential service with sustainable funding mechanisms")
3E. Regulatory Fragmentation
(a) Direct quotes:The only function that remains with another agency is investigating complaints at the EMS agency level, which is delegated to the Office of Inspector General within the Cabinet for Health and Family Services.
A notable gap in Kentucky's EMS legislation is the lack of ability to license and regulate non-transporting EMS organizations.
EMS personnel working in non-transporting fire departments are only able to provide basic first aid at an emergency scene, regardless of their level of licensure.
This 13-member group is comprised of members from the more populated areas of the Commonwealth. These members bring value to the Board. However, the lack of geographical diversity among the membership does not balance the interests and needs of EMS services, clinicians, and the public in underrepresented areas.
While fire service volunteer responders do respond under their first response programs, these programs are not under the direct authority of the Board.(b) Specific data points:
- Board membership: 13 members, reportedly from more populated areas
- 117 PSAPs, including 7 multi-jurisdictional
- Agency-level complaint investigation housed outside the Board (Office of Inspector General)
- Non-transporting EMS organizations cannot be licensed or regulated
- Certificate of Need (CON) remains a requirement for most licensure classes, with limited exceptions enacted in 2022
3F. Data and Evaluation Systems
(a) Direct quotes:In June 2024, KStARS began accepting National Emergency Medical Services Information System (NEMSIS) 3.5 data and set October 31, 2024, as a deadline for Kentucky's complete transition to NEMSIS 3.5. This is a notable and worthy achievement.
he statewide EMS data system does not have uniform connectivity throughout the State, making collection, transmission, and submission difficul
Despite robust data collection, the Board, however, has yet to fully leverage this data to enhance statewide protocol updates or drive systematic quality improvement (QI) initiatives.
Statewide QI efforts in Kentucky remain fragmented.
Obtaining hospital eOutcomes data for backfilling PCRs in State EMS repositories has been notoriously difficult nationwide.
Data submission to State registries is only required by designated facilities and the full impact and occurrence of time sensitive conditions may not be captured.(b) Specific data points:
- Data system: Kentucky State Ambulance Reporting System (KStARS)
- NEMSIS version: transitioned to NEMSIS v3.5 as of June 2024
- Hospital outcome data linkage: not achieved directly; the Board shares data with KIPRC and the Kluger Transportation Research Group at the University of Louisville, which perform linkage
- CARES participation: early stages
- Coverdale grant funding used to work on NEMSIS-to-GWTG-S stroke registry linkage
- KRS 311A.190(8) provides some data protection, but scope unclear
3G. Trauma System Status
(a) Direct quotes:The Kentucky General Assembly passed the Kentucky Trauma Care Law in 2008, but the system remains unfunded.
The Kentucky trauma system has improved, but is not yet fully functional.
Mortality caused by injury in Kentucky is far higher than in other states.
Opportunities for improvement, given the current situation, are non-existent beyond a few isolated injury types as staffing and data resources are insufficient to drive meaningful change.
The Kentucky Trauma System's motto is 'right patient, right care, right time,' but there is little data to verify that this is actually happening.
hese volunteers and the trauma system's leadership lack the time and authority to implement change
There is currently no financial support for hospitals serving as or seeking trauma center designation.(b) Specific data points:
- Trauma Care Law enacted: 2008
- Trauma system: unfunded since enactment
- Trauma system staff: 1 State Trauma Director, funded by a short-term preparedness grant through the Department for Public Health
- Trauma Advisory Committee: 19 volunteer members
- Designated trauma centers as of August 2024:
- 2 Level I Pediatric Trauma Centers
- 1 Level II Trauma Center
- 3 Level III Trauma Centers
- 15 Level IV Trauma Centers (total 24)
- 14 additional hospitals working toward designation
- 100 hospitals with emergency departments
- 1 rural emergency hospital
- 2 children's hospitals (UK Children's Hospital, Lexington; Norton Children's Hospital, Louisville)
- 1 verified burn center (University of Louisville Hospital, 16-bed unit)
- Cardiac care facilities:
- 7 Level II Primary Heart Attack Centers
- 1 Level III Acute Heart Attack Ready Center
- 6 PCI Centers
- 3 Open-heart Surgery Centers
- Stroke centers:
- 19 Primary Stroke Centers
- 1 Thrombectomy-Capable Stroke Center
- 4 Comprehensive Stroke Centers
- Trauma system is voluntary
3H. Medical Direction
(a) Direct quotes:While there is no State EMS Medical Director, the Board contracts with a physician medical advisor whose duties include protocol oversight and approval and participation in select Board activities including the Medical Oversight Committee.
his role lacks the needed capacity and authority to comprehensively address statewide clinical coordination, lead QI initiatives, and serve as the clinical lead for development of statewide systems of care
Medical directors have few requirements to serve in the position and there is great variability across the State in medical director activity and engagement.
less than half of agencies have adopted [the statewide protocols]
No published information or handbook exists for medical directors in Kentucky.
No formal guidelines or education are available statewide for medical directors.
EMS medical director support is highly variable. In many cases, the medical director performs EMS medical director's tasks at little or no charge.
Medical director accessibility to data tools such as monitor case review software is a tiny minority (under 10% based on conversation).(b) Specific data points:
- No State EMS Medical Director; a physician medical advisor is contracted
- Less than half of agencies have adopted statewide protocols
- Medical director compensation in largest services: under 0.3 physician FTE
- Medical director data tool access: under 10%
- Kentucky Chapter of NAEMSP formed 2023, approximately 20 members
- No formal medical director education program exists
3I. Communications and Infrastructure
(a) Direct quotes:All Kentucky counties are presently served by 911, utilizing 117 public safety answering points (PSAPs), including seven that are multi-jurisdictional.
almost all EMS communications systems operate on different bands and frequencies, some of which are not compliant with Federal and State guidelines or standards
interoperability is challenging when agencies need to enter surrounding jurisdictions or one of the seven bordering states
Another challenge facing the State's EMS system is pre-arrival notification to hospital facilities...Due to geographic terrain and technological limitations this is not practical in many areas.
The Board obtained statutory authority to certify PSAPs/emergency medical dispatch centers and their dispatchers in 2018. However, regulations have not been promulgated for either.
No know such statutory or regulatory requirement exists to institute a standard Emergency Medical Dispatcher program.
automated CAD interfaces have not been implemented, nor required by regulation or statute(b) Specific data points:
- 117 PSAPs (including 7 multi-jurisdictional)
- NG911 technology supported statewide
- KY SERVS (statewide trunked radio system) under construction
- EMD statutory authority obtained 2018; regulations not promulgated
- T-CPR program implemented for telecommunicators per Senate Bill 142 (2018) — described as a "component of EMD" but "should not be accepted as a full EMD program"
- SCIP created January 2017, most recent review July 2024
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (1991 Assessment)
This is a reassessment of the original 1991 assessment — a gap of 33 years.
Documented Institutional Knowledge Loss
The report documents significant loss of institutional records and knowledge:
Due to the time since the last evaluation, numerous personnel changes, and changes in overall agency location, it is unknown if a total EMS evaluation of the entire system has ever been completed.
The current staff does not know of any documents or processes from the past that would indicate any formal action on this system-wide assessment.
Due to lost historical data and multiple agency reorganizations and realignments, it is unknown if previous boards completed any actions on the recommendation to conduct a State assessment to determine EMS resources in Kentucky.
Due to lost historical data and multiple agency reorganizations and realignments, the number of ALS agencies licensed to provide care within the Commonwealth during the original 1991 assessment is unknown.
It is unknown when the Board hired an EMS communications consultant, as they have had this position in years past.
Participation in years past is unknown; however, active involvement is not currently being done due to staffing shortages and other implications from the recent reorganization of the State EMS office.
Summary of Progress by Section
Regulation and Policy:- Board established as independent body (2000) — completed
- Comprehensive plan implementation — not completed ("A comprehensive plan has not been implemented.")
- Total EMS system evaluation — status unknown
- Single lead agency established (Board, 2000) — completed
- Licensing and inspection of services — completed
- Assessment of EMS resources — status unknown (records lost)
- Dedicated funding programs — not completed ("No dedicated funding programs were ever implemented")
- ALS coverage: 190 Class 1 agencies now serve 119 of 120 counties — completed (though staffing gaps exist)
- AEMT level implemented (2008) — completed
- National Registry adopted as certification exam (2003) — completed
- Training/education regulations (2003) — completed
- CE training centers established — completed
- EMD program — not completed ("There is no Emergency Medical Dispatcher program in regulation")
- Formal medical director education — not completed
- Volunteer workforce development — not applicable (Kentucky has no volunteer services)
- RN prehospital training — not completed
- Licensing requirements — completed
- Water rescue inventory — not completed
- EMS transportation plan — not completed
- SCIP created (2017) — completed
- Interoperability frequencies adopted — completed
- EMS communications consultant position — not completed (position previously existed, lost through reorganization; no budgeted position)
- Mutual aid system — completed
- EMD requirement — not completed
- Addressing coordination — status unknown
- Trauma Care Law passed (2008) — completed (but unfunded)
- Trauma data bank established — completed
- System-wide QA/PI — not completed
- Was not assessed in 1991. No prior recommendations existed.
- Data protection statute — partially completed (scope unclear)
- QA requirements for agencies — completed
- QA requirements for dispatch — not completed
- NEMSIS-compliant data submission — completed (transitioned to v3.5)
- Hospital outcomes linkage — partially completed (indirect through KIPRC partnership)
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall System Characterization
While the EMS system is seemingly underfunded and understaffed in some key areas, Team Kentucky, including the Kentucky Board of EMS, the Kentucky Department for Public Health, the Kentucky Office of Highway Safety, and the Kentucky Office of Homeland Security are dedicated to building collaborative partnerships in order to improve the health and safety of people in Kentucky through prevention, protection, preparedness, response, and recovery.
The geographic, demographic, and socioeconomic statistics highlight some of the challenges facing the State's healthcare system and the need to enhance Kentucky's emergency medical services system; however, there are also many positive aspects.
Structural Barriers Identified
The report identifies multiple structural barriers:
1. No essential service designation — EMS agencies are "non-essential" under state law
2. Inability to regulate non-transporting agencies — described as a "notable gap"
3. Complaint investigation authority housed outside the Board (Office of Inspector General)
4. Certificate of Need process restricts new service creation
5. Board geographic composition — membership drawn from more populated areas
6. Trauma system lacks funding authority — Trauma Care Law passed in 2008 but unfunded
7. Trauma Advisory Committee members lack authority — "lack the time and authority to implement change"
8. No mechanism for statewide EMS planning beyond the statutory requirement
Transportation vs. Healthcare Framework
The report explicitly operates within the transportation/highway safety framework:
NHTSA is charged with reducing death and injury on the nation's highways.
At the core of this strategy is the adoption of the Safe System Approach which focuses on five key objectives: safer people, safer roads, safer vehicles, safer speeds, and post-crash care.
The report also references Section 402 funds:
Guideline No. 11 allows States to utilize highway safety funds to support a tool to use over time in assessing the effectiveness of their EMS programs.
However, health system integration language is present:
supports the development of a comprehensive and integrated State health management system
Federal Funding Mechanisms Referenced
- Section 402 highway safety grant funds
- EMSC grant ($174,300)
- Hospital Preparedness Program (HPP)
- Coverdale grant funding (stroke data linkage)
- Kentucky 911 Services Board telephone service fees
Greatest Strengths (as identified by the TAT)
- Board establishment as a single lead agency (2000)
- NEMSIS v3.5 transition — "a notable and worthy achievement"
- EMSC Program active since 1996 with generally high participation
- Traffic Incident Management (TIM) implementation — Board "commended for its continued dedication and successful implementation"
- Advanced Practice Paramedic (APP) licensure development
- Healthcare preparedness system — "emerged as a leader in Region IV"
- Partnerships with KIPRC and Kluger Transportation Research Group for data analysis
Most Critical Challenges (as identified by the TAT)
- No comprehensive statewide EMS plan (unfulfilled since 1991)
- EMS not designated as an essential service
- Inadequate and unsustainable funding
- Paramedic workforce shortage, particularly in rural areas
- Unfunded trauma system with injury mortality "far higher than in other states"
- No State EMS Medical Director (contracted medical advisor lacks capacity and authority)
- 117 PSAPs without EMD or prioritized dispatching
- Inability to license/regulate non-transporting EMS agencies
- Fragmented QI — no system-wide quality assurance program
- Significant institutional knowledge loss between 1991 and 2024
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
33-Year Gap Between Assessment and Reassessment
The original assessment was conducted in 1991 and this reassessment occurred in 2024 — a 33-year gap. This is among the longest intervals documented in the NHTSA assessment program. The report repeatedly notes that institutional knowledge has been lost, records cannot be located, and the status of many 1991 recommendations is unknown.
No Volunteer EMS Services
Kentucky currently has no volunteer services in operation.
This is a notable finding. While fire service volunteers respond to emergencies, they operate under first response programs not under Board authority, and due to the regulatory gap around non-transporting agencies, these volunteer firefighter-EMS personnel can only provide basic first aid regardless of their licensure level.
Unfunded Mandates/Programs
Multiple programs have been authorized or enacted but remain unfunded:
- Kentucky Trauma Care Law (2008) — 16 years unfunded
- 2024 EMS training grant program — enacted but unfunded
- CARES initiative — early stages, funding needed
- No financial support for time-sensitive emergency planning, data collection, or operations
Injury Mortality Statement
Mortality caused by injury in Kentucky is far higher than in other states. Opportunities for improvement, given the current situation, are non-existent beyond a few isolated injury types as staffing and data resources are insufficient to drive meaningful change.
This is one of the most direct and severe statements in the report, linking structural deficiencies (staffing and data) directly to an inability to reduce preventable death.
Trauma System Motto vs. Reality
The Kentucky Trauma System's motto is 'right patient, right care, right time,' but there is little data to verify that this is actually happening.
Non-Transporting Agency Regulatory Gap
EMS personnel working in non-transporting fire departments are only able to provide basic first aid at an emergency scene, regardless of their level of licensure.
This creates a paradox where licensed paramedics staffing fire department first response units are legally restricted to basic first aid because the fire department cannot be regulated as an EMS agency.
Medical Direction Compensation
Kentucky's largest EMS services compensate the medical director at a rate of under 0.3 physician FTE based on average US EM physician compensation.
Medical director accessibility to data tools such as monitor case review software is a tiny minority (under 10% based on conversation).
Statewide Protocol Adoption Rate
less than half of agencies have adopted [the statewide protocols]
Testimony highlighted the lack of timely update of the protocols as a possible contributor to such low adoption.
Loss of Board Staffing and Capabilities
Multiple references to degraded Board capacity due to reorganization:
- Marketing specialist lost in 2021 — annual report no longer produced
- EMS communications consultant position lost — no budgeted replacement
- Active involvement in multiple activities "not currently being done due to staffing shortages and other implications from the recent reorganization of the State EMS office"
Certificate of Need as Barrier and Modifier
The CON remains required for most EMS licensure classes. A 2022 legislative change allows counties/cities to establish services via public hearing without a CON, but with significant restrictions:
he license is limited to providing emergency runs that terminate at the emergency room and some restricted emergency interfacility transports
Southern Border Trauma Development
Fourteen of the fifteen centers currently in development are along the State's southern border, and efforts to recruit facilities in the far western counties will continue.
This geographic pattern in trauma center development is notable for its concentration along one border region.
Board Realignment History
The Board has undergone multiple reorganizations, most recently in 2022 when it was "realigned back into State government." These reorganizations have resulted in staffing losses, logo changes, and institutional knowledge gaps documented throughout the report.
Analysis completed per standardized NHTSA State EMS Assessment framework. No synthesis or editorial interpretation has been applied. Findings are extracted as documented in the report.
Maryland
Full Analysis
Maryland 2004 NHTSA State EMS Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of Maryland
- Report type: Reassessment
- Date of site visit: June 1–3, 2004
- Year of publication: 2004
- Prior assessment year: 1991
- TAT members:
- Herbert G. Garrison, MD, MPH — Professor and Interim Chair, Department of Emergency Medicine, East Carolina University; Co-PI, EMS Outcomes Project (NHTSA-funded)
- Robert Mackersie, MD, FACS — Director of Trauma Services, Acting Chief of Surgery, San Francisco General Hospital; Chair, ACS Committee on Trauma Systems Consultation; Professor of Surgery, UCSF
- W. Dan Manz — Director, EMS Division, Vermont Department of Health; Past President, NASEMSD; Co-Chair, EMS Agenda for the Future; PI, National Scope of Practice Model Project; Member, IOM Emergency Medical Care Subcommittee
- Susan McHenry — EMS Specialist, NHTSA (NHTSA facilitator); Past President, NASEMSD
- Drexdal Pratt — Chief, Office of EMS, North Carolina
- NHTSA facilitator: Susan McHenry
- Number of presenters/briefings: Over 30 presenters
- Requesting agency: Maryland Institute for Emergency Medical Services Systems (MIEMSS), in concert with the Maryland Governor's Highway Safety Office
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not explicitly stated.
- Geographic characteristics: Not described in detail. The report references both urban areas (Baltimore City, metropolitan Baltimore) and rural areas. Proximity to the nation's capital and coastal harbors noted in Homeland Security context (p. 40).
- Number of counties/jurisdictions: Not explicitly counted. The report references "jurisdictions" throughout and notes 5 adult and 5 pediatric regional medical directors.
- EMS system overview:
- Governance structure: 11-member EMS Board appointed by the governor provides oversight and regulatory authority. 29-member State Emergency Medical Services Advisory Committee (SEMSAC) provides broad stakeholder participation. MIEMSS is the operational lead agency, funded through an EMS Operating Fund.
- Executive Director: Robert Bass, MD (physician serving as executive director)
- State EMS Medical Director: Full-time position; separate from the Executive Director
- Additional medical directors: Full-time air medical program medical director; 2 part-time pediatric medical directors; 5 adult and 5 pediatric regional medical directors (MIEMSS-stipended)
- Number of agencies/providers: Over 30,000 certified or licensed career and volunteer personnel (907 EMDs, 11,034 FRs, 15,548 EMT-Bs, 626 CRTs, 2,322 EMT-Ps); over 600 public service EMS vehicles; 116 BLS + 131 ALS + 7 neonatal commercial ground ambulances; MSP Aviation Division with 12 helicopters (8 available 24/7); 3 commercial helicopters + 1 fixed wing; 48 hospitals with emergency departments; 25 training programs (community colleges, academies, hospitals)
- Notable demographic or socioeconomic factors cited: The report references CDC 2001 data that injuries were the leading cause of death for ages 1–34 in Maryland (p. 28). Volunteer workforce issues and career staffing trends are noted ("many areas in the state are adding career staff," p. 19). Proximity to Washington, DC, harbors, and "high profile structures" are cited as terrorism risk factors (p. 40).
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:The law included a requirement that the Maryland EMS Board develop and adopt an EMS Plan. The Board followed through on that commitment and adopted the state's first plan in August 1995." (p. 11)
The list of goals and objectives, which is the plan, was updated in 2000 and again in 2002/2003." (p. 11)
The plan as written does not include current system strengths or weaknesses nor does it identify future directions." (p. 13)(b) Specific data points: State EMS plan adopted August 1995, updated 2000 and 2002/2003. Legislatively mandated. Described as a "list of goals and objectives" rather than a comprehensive strategic document. (c) TAT characterization: The TAT acknowledges the plan exists and is legislatively mandated but identifies it as insufficient — a list of goals and objectives rather than a comprehensive vision with strengths, weaknesses, and future directions. This is a notably nuanced criticism of a state that actually has a plan. (d) Priority recommendation: Yes (bold, pp. 12, 14):
Expand and revise the Maryland EMS plan. Include a comprehensive vision for the system in light of the EMS Agenda for the Future that includes a level of detail identifying EMS services, strategies, commitments and operations. Establish benchmarks for system performance as part of the plan.
Develop a comprehensive State EMS plan. Include objectives relating to the EMS role in Homeland Security activities.
3B. Funding and Financial Sustainability
(a) Direct quotes:In 1992, secure funding for MIEMSS and the major components of the state EMS system was established through a motor vehicle registration fee surcharge." (p. 11)
Over time, the fee has evolved to its current level of $11.00 and provides funding for the operating expenses of MIEMSS, support to the Maryland State Police Aviation Division, the Maryland Fire and Rescue Institute, the R Adams Cowley Shock Trauma Center, the Amoss Fire, Rescue and Ambulance Fund, and the Volunteer Company Assistance Fund." (p. 11)
Senate Bill 479 called for a two year study of EMS and allocated an additional $2.50 of the vehicle registration fee for on-call specialty physician coverage in trauma centers." (p. 11)
Funding from motor vehicle registration fees provides an EMS Operating Fund that appropriately supports the needs of the system." (p. 8)(b) Specific data points:
- $11.00 motor vehicle registration fee surcharge — dedicated EMS Operating Fund (since 1992)
- Additional $2.50 per registration for trauma center specialty physician coverage (SB 479)
- Fund supports: MIEMSS operations, MSP Aviation Division, Maryland Fire and Rescue Institute, R Adams Cowley Shock Trauma Center, Amoss Fire/Rescue/Ambulance Fund, Volunteer Company Assistance Fund
- Federal terrorism preparedness funding: "only a very small percentage" reaching EMS systems (p. 40)
- Specific dollar amounts for MIEMSS budget or total fund: not documented
Assure the continuation of secured funding to support the activities of MIEMSS and related EMS system needs." (p. 14)
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:The current EMS workforce exceeds thirty thousand certified or licensed career and volunteer personnel." (p. 14)
There is a perceived shortage of EMT-Ps in Maryland although this has not been determined through any formal needs assessment process." (p. 16)
MIEMSS is concerned about the adequacy of the state's EMS workforce overall and has established a task force to monitor the situation." (p. 16)
Baltimore City has an all paid/career services program and many areas in the state are adding career staff." (p. 19)(b) Specific data points:
- Over 30,000 certified/licensed personnel
- 907 EMDs; 11,034 FRs; 15,548 EMT-Bs; 626 CRTs; 2,322 EMT-Ps
- Perceived EMT-P shortage — no formal needs assessment completed
- Task force established to monitor workforce adequacy
- CRT level being aligned with National EMT-I/99
- Training at 25 community colleges, academies, or hospitals
- AED program: 360 facilities, 758 sites, 9,500 trained persons; 60 cardiac arrests since 2000, 18% ROSC at EMS arrival
- No reported shortage in training program access or quality
Perform a formal needs assessment to determine the anticipated workforce needs of the Maryland EMS system.
3D. Essential Service Designation
(a) Direct quotes: Not documented in this report. (b)-(d): N/A — not addressed. Maryland's independent agency structure and dedicated funding mechanism effectively treat EMS as a state-supported service without using the "essential service" terminology.3E. Regulatory Fragmentation
(a) Direct quotes:MIEMSS has pursued two different pathways to regulate ambulance services. There are specific standards and requirements for commercial ambulance services. The requirements for public ambulance services are less definitive, relying more heavily on jurisdictional oversight and a requirement for quality improvement plans." (p. 12)
While this approach arguably creates two different levels of protection for the public, it appears to be working but may not be the ideal long term approach." (p. 12)(b) Specific data points:
- Two regulatory pathways: commercial (licensed) vs. public (voluntary inspection/QI-based)
- Voluntary Ambulance Inspection Program (VAIP) implemented in 13 jurisdictions and expanding
- Public service ambulance providers not licensed in Maryland
- Commercial fleet data well documented; public sector data less complete
Examine the feasibility of combining the regulatory approaches of the Commercial Ambulance Licensing program with the quality improvement orientation applied to public sector ambulance services." (p. 12)
3F. Data and Evaluation Systems
(a) Direct quotes:A weak link in the current evaluation system is the lack of patient outcome data." (p. 39)
The philosophy of keeping most QA/QI 'local' may keep the state office from fully utilizing the large amount of statewide data it already collects." (p. 38)
The creation of the EMAIS presents an opportunity for MIEMSS to vastly improve its dissemination efforts." (p. 39)
All EMS providers are required to submit data to MIEMSS and have been meeting this requirement using a paper EMS run report." (p. 14)(b) Specific data points:
- Paper-based run report system statewide (mandatory)
- Electronic Maryland Ambulance Information System (EMAIS): piloting in 5 counties
- Facility Resource Emergency Database (FRED): web-based real-time hospital resource inventory (developed 2002, enhanced April 2004)
- Trauma registry: "Collector" platform, data from designated trauma centers only — no NTC data, no NTDB submission
- Data linkage capability: in planning (EMAIS to outcome data, NEMSIS, other databases)
- QI confidentiality: legislative protection exists
- Statewide QI program: regulations require jurisdictional QA plans approved by local then state medical director
- CODES project or similar linkage: not documented as operational
- Dissemination of evaluation findings: described as "limited" (p. 39)
Implement the electronic Maryland ambulance information system statewide and complete the linkages with other healthcare systems.
Improve dissemination of evaluation information to local providers. Develop a system whereby local providers receive timely information on every aspect of the care they provide along the continuum from the time the call is received through patient discharge and outcome.
Determine standard optimal system performance benchmarks and indicators ('results'); monitor, track, report and act on these results in a timely fashion.
3G. Trauma System Status
(a) Direct quotes:Since the last NHTSA assessment in 1991, the Maryland trauma system has been further developed under enabling EMS legislation in 1993." (p. 34)
Other than these regulations, however, there is no current trauma plan although it appears that one was originally developed circa 1992." (p. 34)
In May of 2002, Western Maryland's Washington County Hospital, a Level II trauma center, requested a temporary suspension of its trauma center status due to a lack of physician coverage for trauma call." (p. 35)(b) Specific data points:
- 1 Primary Adult Resource Center (PARC)
- 1 Level 1 adult trauma center
- 4 Level 2 adult trauma centers
- 3 Level 3 adult trauma centers
- 2 Level 1 pediatric trauma centers (includes out-of-state)
- 1 eye trauma center; 1 neurotrauma center; 1 hand/upper extremity center; 1 hyperbaric medicine center; 2 burn centers (includes out-of-state); 16 perinatal referral centers (includes out-of-state)
- Trauma center verification: internal MIEMSS process, 5-year cycle (vs. ACS 3-year)
- Trauma registry: "Collector" platform; designated centers only; no NTC data; no NTDB submission
- No current trauma plan document
- Trauma Network: principal advisory committee (no legislative provision)
- SB 479: additional vehicle registration fee for trauma center physician coverage
- TraumaQIC: system PI committee; physician involvement described as "spotty"
Write a new state trauma plan (or component of the EMS plan) incorporating current elements of the Maryland trauma system and addressing trauma specific goals and objectives.
Conduct a formal external assessment of the Maryland Trauma System.
3H. Medical Direction
(a) Direct quotes:The active involvement of physicians at all levels of the Maryland EMS system is a major reason that the state can boast that it provides its citizens and visitors with a level of emergency medical care that is unsurpassed." (p. 31)
Maryland has two full-time medical directors at the state level: the State EMS Medical Director and the medical director for the air medical program. There are also two part-time pediatric medical directors." (p. 31)
Having a physician as the executive director sets the tone that the system exists to meet the emergency medical needs of the citizens of Maryland." (p. 31)
here are no criteria for selecting company or squad level medical directors and for training and monitoring them once they become part of the system." (p. 32)
Attendance at the Maryland Medical Direction Course, the statewide annual symposium or the regional meetings is voluntary." (p. 32)(b) Specific data points:
- 2 full-time state-level medical directors (EMS + air medical)
- 2 part-time pediatric medical directors
- 5 adult + 5 pediatric regional medical directors (MIEMSS-stipended)
- Standardized criteria for state/regional medical director selection; standardized job descriptions
- Qualification and performance criteria for EMS Operational Program Medical Directors
- Maryland Medical Director Orientation Course exists
- Hospital on-line medical direction staff: must complete MIEMSS-approved base station course + annual protocol update
- Company/squad-level medical directors: no selection criteria, no required training, no monitoring
- BLS and ALS protocols in one comprehensive document
- QI confidentiality protection: exists in statute
Integrate company and squad level physicians into the MIEMSS medical direction system; develop standards for the selection, training and monitoring of these physicians.
Require a minimal level of formal preparation for all off-line medical direction physicians.
3I. Communications and Infrastructure
(a) Direct quotes:Maryland is one of the first states to implement a statewide communication system that enables field personnel to contact online medical control and then be patched through the communications network to referral centers and receiving facilities." (p. 27)
all counties in Maryland have implemented the EMD program and offer pre-arrival instructions" (p. 27)(b) Specific data points:
- Statewide E-911 (legislation 1985; enhanced 911 legislation 1995)
- All counties have EMD with pre-arrival instructions
- EMSTEL: integrated EMS telephone network connecting dispatch centers, trauma centers, specialty centers, EMRCs, SYSCOM
- General Assembly authorized comprehensive communications study 1999; funds allocated for digital microwave infrastructure
- Wireless 911 ALI: not yet available
- 10-year planning initiative for migration to 700 MHz spectrum
- Statewide interoperability governance committee established 2003
- FRED: web-based real-time hospital resource database
Complete the building and implementation of the statewide digital microwave network.
Link FRED and other data systems such as the public health syndromic surveillance system to include the prehospital providers.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (1991 Assessment)
The report combines Status and Progress sections. Due to the 13-year gap and the comprehensive nature of the 1993 legislation, the TAT treats progress thematically rather than recommendation-by-recommendation.
Major Accomplishments Since 1991:
- 1993 EMS legislation establishing MIEMSS as independent state agency with EMS Board
- EMS Operating Fund via motor vehicle registration surcharge ($11.00 + $2.50)
- State EMS Plan adopted 1995, updated 2000, 2002/2003
- COMAR Title 30 regulations covering all essential EMS system components, updated approximately annually
- Trauma center designation system with verification process (PARC, Levels 1–3, pediatric, specialty centers)
- Disease-based systems of care development (trauma, stroke, cardiac, perinatal)
- FRED — web-based real-time hospital resource database (2002)
- Statewide EMD in all counties with pre-arrival instructions
- Full-time state medical directors (EMS + air medical) and regional medical director structure
- Comprehensive QI program with regulatory requirements
- EMAIS electronic patient care report piloting
- Neonatal Transport Program (~700 transports/year)
- Layperson AED program (360 facilities, 9,500 trained)
- EMS-C program recognized as leading nationally
- WMD strategic plan and protocols
- SB 479 — new funding for trauma center physician coverage
Areas Identified as Still Needing Work:
- EMS plan lacks comprehensive vision, strengths/weaknesses, future directions
- No electronic patient care report statewide (paper-based, EMAIS piloting in 5 counties)
- No patient outcome data linkage
- No trauma plan document
- No trauma system medical director
- Internal trauma verification process not validated against ACS
- Dual regulatory pathways for public vs. commercial ambulance services
- Company/squad medical directors not integrated into state system
- Limited NTC integration in trauma system
- Wireless 911 ALI not available
- Dissemination of evaluation findings limited
- No formal workforce needs assessment
- Limited rehabilitation integration
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization of the EMS system:This is the most positive assessment in this analysis corpus. The TAT describes Maryland as "a state with a mature and sophisticated statewide EMS system" (p. 8) and uses language of national leadership:
Maryland EMS is unique in beginning to apply a disease-based model to develop its system of emergency care for trauma, stroke, cardiac, and perinatal patients." (p. 8)
he state can boast that it provides its citizens and visitors with a level of emergency medical care that is unsurpassed." (p. 31)
another challenge is for the state to offer national leadership in promoting the continued development and improvement of other state systems." (p. 9)
The greatest asset that Maryland's EMS system possesses is its people." (p. 9)
The TAT traces the system's origins:
The origin of the system is traceable to the vision and force of personality of R Adams Cowley, MD. He believed that seriously injured patients would have better outcomes if they could arrive quickly and reliably at a trauma center." (p. 8)
That vision has been expanded by the EMS Board's contemporary approach of cooperative excellence and the Executive Director's program of quality improvement." (p. 9)Structural barriers identified:
The TAT identifies relatively few structural barriers compared to other assessments:
- Dual regulatory pathway (commercial vs. public ambulance services)
- Paper-based data system limiting evaluation capability
- Absence of patient outcome data linkage
- Local QI philosophy potentially limiting statewide evaluation
- Company/squad medical directors outside the state system
- No current trauma plan; no trauma system medical director
- Internal trauma verification not validated against ACS
- Rehabilitation not integrated into disease-based care systems
- Wireless 911 ALI not available
- Federal terrorism preparedness funding not reaching EMS
The Background reflects the NHTSA transportation framework. However, the body of the report operates almost entirely within a healthcare framework. The disease-based systems of care approach — trauma, stroke, cardiac, perinatal — represents the most advanced healthcare integration documented in any NHTSA assessment in this corpus. The TAT explicitly notes:
By using this approach, the state is making excellent progress towards meeting the NHTSA standards." (p. 8)
The Homeland Security section (added at the state's request) introduces a third framework — emergency preparedness — alongside transportation and healthcare.
Federal funding mechanisms referenced:- Highway safety funds — assessment program mechanism
- Federal terrorism preparedness funding — "only a very small percentage" reaching EMS (p. 40)
- Motor vehicle registration fee surcharge as state dedicated funding (not federal)
- MIEMSS as independent state agency with dedicated funding
- "Cooperative excellence" philosophy
- Physician executive director setting medical tone for system
- Full-time state medical directors with regional structure
- Disease-based systems of care (national model)
- FRED — real-time hospital resource database
- Statewide EMD with pre-arrival instructions in all counties
- Statewide integrated communications system (EMSTEL/EMRC/SYSCOM)
- MSP Aviation Division — 12 helicopters, 8 available 24/7
- COMAR Title 30 regulatory framework updated approximately annually
- EMS-C program recognized as leading nationally
- Layperson AED program (9,500 trained, 18% ROSC)
- Neonatal Transport Program (~700 transports/year)
- WMD preparedness planning
- MIEMSS staff described as "committed and capable"
- Implementing electronic patient care report statewide
- Establishing patient outcome data linkages
- Developing comprehensive EMS plan (beyond goals/objectives)
- Perceived paramedic workforce shortage (unconfirmed)
- Maintaining funding adequacy
- Preserving MSP Aviation core function amid commercial helicopter interest
- Preparing for terrorism/mass casualty events
- Integrating rehabilitation into disease-based care
- Connecting EMS with public health syndromic surveillance
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. Most advanced EMS system in this analysis corpus. Maryland in 2004 represents the high-water mark among the six assessments analyzed thus far. The TAT explicitly challenges Maryland to "offer national leadership" to other states (p. 9) — a recommendation to lead rather than to fix. This is categorically different from the structural deficit findings in Massachusetts (1992), Colorado (1997), California (1999), Connecticut (2000), and South Dakota (2002).
2. Disease-based systems of care as paradigm shift. Maryland's development of disease-specific systems (trauma, stroke, cardiac, perinatal) with designated/verified specialty centers represents a conceptual advance beyond the traditional EMS system components approach. The TAT describes this as "unique" nationally (p. 8) and notes it as a model for meeting NHTSA standards through a healthcare rather than transportation framework.
3. R Adams Cowley's legacy explicitly cited. The report traces the system's origin to Cowley's vision and notes the continuity from his original concept through the current EMS Board and Executive Director (p. 8). This is a rare instance of a NHTSA assessment explicitly acknowledging the historical lineage of a state EMS system.
4. Physician executive director. The TAT notes that having a physician (Robert Bass, MD) as the MIEMSS Executive Director "sets the tone that the system exists to meet the emergency medical needs of the citizens" (p. 31). This observation — that the professional identity of the agency leader shapes institutional culture — is unique in the assessment literature.
5. Independent state agency model. MIEMSS operates as an independent state agency rather than a division within a health department. The TAT states this "has served Maryland well" and notes the ability "to focus on its stated Mission, Vision, and Values without the compromises that might be necessary if it were housed within a larger state agency" (p. 11). This endorsement of institutional independence is significant.
6. $11.00 + $2.50 motor vehicle registration fee. The dedicated EMS Operating Fund from vehicle registration surcharges, described as "appropriately support[ing] the needs of the system," represents the most robust dedicated funding mechanism documented in this analysis corpus. The legislative response to the Washington County Hospital crisis (SB 479 adding $2.50) demonstrates the system's capacity for adaptive revenue generation.
7. Trauma center crisis as catalyst. Washington County Hospital's 2002 suspension of Level II trauma center status due to physician coverage shortfalls (p. 35) documents a concrete system-level failure that catalyzed legislative action (SB 479). This event illustrates how even mature systems face physician workforce challenges.
8. Recommendations as refinements, not corrections. The character of the recommendations differs fundamentally from other assessments. Rather than establishing basic infrastructure (plans, lead agencies, medical directors, data systems), Maryland's recommendations focus on enhancement: expanding the plan, implementing electronic records, linking data systems, integrating rehabilitation, validating the internal verification process against ACS. The system's challenges are optimization problems, not foundational deficits.
9. MSP Aviation Division as "core competency." The TAT identifies the Maryland State Police Aviation Division as a "core competency within the State EMS system" (p. 20) and recommends preserving its trauma scene response function amid growing commercial helicopter interest. This framing of a police aviation unit as an EMS system core competency is distinctive.
10. Homeland Security as 11th component. As with California (1999, Disaster Systems), Maryland requested an additional assessment component — Homeland Security — reflecting post-9/11 priorities. The TAT notes that EMS is receiving "only a very small percentage of federal funding to states for terrorism preparedness" (p. 40) and recommends advocacy for equitable distribution.
11. "Unsurpassed" — the most superlative characterization. The TAT's statement that Maryland provides "a level of emergency medical care that is unsurpassed" (p. 31) is the strongest positive characterization in any NHTSA assessment in this analysis corpus. Applied specifically to physician involvement and medical direction, it positions Maryland as the national benchmark.
Analysis extracted: February 2026. Source document: State of Maryland, A Reassessment of Emergency Medical Services, NHTSA Technical Assistance Team, June 1–3, 2004.
Massachusetts
Full Analysis
Massachusetts 1992 NHTSA State EMS Assessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Commonwealth of Massachusetts
- Report type: Assessment
- Date of site visit: March 17–19, 1992
- Year of publication: 1992
- Prior assessment year: N/A (initial assessment)
- TAT members:
- Valerie A. Gompf — Highway Safety Specialist, NHTSA EMS Division (NTS-42)
- Tim Hynes — Director, Emergency Medical Services, Salt Lake City Fire Department
- Jon R. Krohmer, MD, FACEP — Medical Director, Kent County EMS; Assistant Program Director, Emergency Medicine Residency, Butterworth Hospital; Assistant Professor, Section of Emergency Medicine, Michigan State University
- Arthur L. Trask, MD, FACS — Fairfax Hospital, Falls Church, VA; Clinical Assistant Professor, University of South Florida; Clinical Professor, University of Miami
- Barak Wolff, NREMT-B, MPH — Chief, Primary Care and EMS Bureau, Public Health Division, NM Department of Health; Past President, NASEMSD
- NHTSA facilitator: Valerie A. Gompf (identified as NHTSA staff; no separate facilitator named)
- Number of presenters/briefings: Over 30 presenters
- Requesting agency: Commonwealth of Massachusetts Department of Public Health, Office of Emergency Medical Services, in concert with the Commonwealth of Massachusetts Department of Public Safety, Governor's Highway Safety Bureau
SECTION 2: STATE CONTEXT
- Population (as cited in report): 6 million residents (p. 13, Transportation section)
- Geographic characteristics: The report references urban, suburban, and rural populations. Central and western Massachusetts are characterized as rural with extended response times. No square mileage figure is cited.
- Number of counties/jurisdictions: Not explicitly stated. The report references five EMS Regional Councils and notes local government autonomy as a factor (referencing "Prop 2½" and "local government autonomy," p. 25).
- EMS system overview:
- Governance structure: State lead agency (OEMS) with five regional EMS councils whose functions are defined in regulation (105 CMR 170.100 to 106). Each region operates under a contract with the state, but deliverables vary by region.
- Number of agencies/providers: 307 licensed ground and air ambulance services; 855 ground ambulances; 2 helicopters (with a third approved); 13,000+ prehospital care providers (12,258 EMT-Basic; 328 EMT-Intermediate; 817 Paramedic)
- Director: Frank Keslof, OEMS Director
- Notable demographic or socioeconomic factors cited: The report extensively discusses declining state revenues and an economic downturn:
Massachusetts is experiencing a difficult period as the state confronts declining revenues, thus reducing the resources available to deal with public health issues." (p. 5, Introduction)
The report also references "Prop 2½" (a property tax limitation measure) and "local government autonomy" as external constraints on trauma system development (p. 25).
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:Massachusetts does not have a current statewide EMS plan." (p. 9)
The state office has had declining resources, which perhaps accounts for not focusing on the development of a plan." (p. 9)
failing to plan is planning to fail" (p. 5)
We are convinced that the process of bringing the stakeholders together and developing a common vision for the future is more important than the planning document that will result, because developing a shared vision will enable the stakeholders to work with legislative and executive staffs to move the vision toward a new reality." (p. 5)
The need to develop plans is a theme that is repeated throughout the team's recommendations." (p. 5)(b) Specific data points: No statewide EMS plan exists. No plan has existed in the recent past. A regional structure exists with five councils operating under varying contracts. (c) TAT characterization: Planning is treated as the foundational deficit pervading the entire system. The introduction elevates this to a philosophical imperative, citing Proverbs 29:18 ("Where there is no vision, the people perish") and Eisenhower ("Plans are nothing and planning is everything," quoted p. 10). (d) Priority recommendation: Yes. The recommendation to develop a State EMS Plan is in bold italics (p. 10):
Massachusetts must develop a State EMS Plan. The plan should be a vision for a statewide EMS system through the year 2000, and should consider the recommendations of this report.
3B. Funding and Financial Sustainability
(a) Direct quotes:There is no dedicated EMS funding mechanism to support either the provision of EMS services at the local level or the operation of the state EMS office." (p. 6)
This represents a considerable reduction in total funding to EMS from what it was in the late 1970s under the categorical EMS grants and from the combination of state and federal funding throughout most of the 1980s." (p. 7)
State funding was reduced during the economic crunch that hit the Commonwealth in the late 80s. This negatively impacted both the state EMS office and regional councils." (p. 7)
This has been compounded by the various cutbacks in funding that have left OEMS focusing almost exclusively on training coordination, examination and certification of personnel, ambulance inspection and licensure, and enforcement activities." (p. 7)(b) Specific data points:
- ~$150,000/year in state general fund support for OEMS (supports ambulance inspection and enforcement program only)
- $500,000 from the Federal Preventive Health and Health Services Block Grant for OEMS operations
- $500,000 from the same Block Grant in contractual support to the five EMS Regional Councils
- ~$50,000/year since mid-1980s from NHTSA Section 402 funds via Governor's Highway Safety Office (used for training projects)
- >$300,000 in NHTSA-funded specialized training programs since 1986 (p. 11)
- Total identifiable state-level EMS funding: approximately $1.2 million/year from combined state and federal sources
- Block Grant had increased by more than 35% in current federal fiscal year, but no mention of whether EMS would receive additional funding (p. 7)
exploration of potential dedicated EMS financing mechanisms" (p. 8)
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:Based on information provided to the team, there appears to be an abundance of properly trained prehospital providers." (p. 11)
Rural services rely heavily on volunteer staffing. Testimony indicated coverage may be inconsistent." (p. 11)
Rural providers expressed some difficulty in obtaining quality continuing education." (p. 11)
Nearly 100% of the population is serviced by EMS providers certified at an EMT level. More than 80% of the population has access to ALS service. However, it is unclear what percent has 24-hour ALS coverage." (p. 11)(b) Specific data points:
- 13,000+ total prehospital care providers
- 12,258 EMT-Basic certified
- 328 EMT-Intermediate certified
- 817 Paramedic certified
- ~100% of population served by EMT-level providers
- >80% of population with access to ALS service
- 24-hour ALS coverage percentage: unknown
3D. Essential Service Designation
(a) Direct quotes: Not documented in this report. The report does not use the phrase "essential service" in reference to EMS designation. (b) Specific data points: N/A (c) TAT characterization: The report does not explicitly address or recommend essential service designation for EMS. However, the report does address the institutional status of EMS implicitly by noting OEMS's constrained role and recommending the expansion of the "lead agency" responsibilities and a re-evaluation of the "definition and conceptual basis for EMS in Massachusetts" (p. 8). (d) Priority recommendation: N/A — not addressed.3E. Regulatory Fragmentation
(a) Direct quotes:One of the concerns apparent to the team is the lack of clarity in the scope and function of OEMS as the 'lead agency' for EMS, particularly in regards to the delegation of roles and responsibilities to the regional councils." (p. 7)
In some areas it appears that the regions should be functioning in a more coordinated and synergistic fashion with one another and with OEMS." (p. 7)
he expectations (deliverables) vary from region to region" (p. 9)
Each region has ALS protocols, while BLS protocols are not universally available." (p. 9)
The roles and responsibilities of regional and local agency medical directors vary from region to region. Several presenters provided varying descriptions and perspectives regarding their expectations and roles." (p. 22)(b) Specific data points:
- 5 EMS Regional Councils
- 97 acute care medical facilities
- Basic 9-1-1 covers 42% of population (enhanced 9-1-1 being introduced)
- C-MED system covers most but not all of the state
- No count of PSAPs or dispatch centers is provided
here is currently no guidance in the areas of Do Not Resuscitate (DNR) orders, point of entry requirements, or regulation of hospital-based non-transport services." (p. 7)(d) Priority recommendation: Yes. The recommendation to review and expand the Emergency Medical Care Act (bold italics, p. 8) includes expanding "lead agency" responsibilities and clarifying regional roles. The State EMS Plan recommendation (bold italics, p. 10) also targets this issue.
3F. Data and Evaluation Systems
(a) Direct quotes:There is no statewide EMS run form. Similarly, there is no requirement for uniform reporting of EMS data to either the state or regional level." (p. 26)
it appears that the lack of uniform data collection impedes the ability to coordinate quality improvement activities." (p. 26)
There is no consistent mechanism for follow-up and disposition reporting on EMS patients from the hospitals to which they are transported." (p. 27)
Continuous quality improvement can not occur because there is no data on mortality or morbidity of trauma patients within the state. Also there is no data on the number of injuries or the severity of injuries." (p. 24)
There is no mechanism to ensure the confidentiality and nondiscoverability of quality improvement activities in the EMS setting." (p. 27)(b) Specific data points:
- No statewide EMS run form
- No uniform reporting requirement
- No statewide trauma registry
- EMS run forms completed only for AED, intermediate, and paramedic runs — no consistent documentation from first responders or basic EMTs
- Verified trauma centers have individual registries, but there is no consistency among them and little/no sharing of information
- No patient outcome linkage capability
- No statutory QI confidentiality protections
3G. Trauma System Status
(a) Direct quotes:There is not a fully functional EMS system and/or a plan to develop same. There is no enabling legislation or proposed legislation for the development of a trauma system." (p. 24)
A comprehensive statewide trauma system plan has not been developed." (p. 24)
A statewide trauma registry does not exist. Mandatory post mortem examination legislation for trauma victims who die has not been enacted." (p. 24)
The components of a trauma system which are in place are disjointed and not coordinated. Dialogue between centers and within centers doesn't take place." (p. 24)(b) Specific data points:
- 5 trauma centers referenced (described as "well recognized" adult and pediatric trauma centers plus burn centers, but no formal level designations verified)
- No enabling legislation for trauma system
- No statewide trauma registry
- No mandatory autopsy law for trauma deaths
- No statewide triage criteria for trauma patient evacuations (ground or air)
- No trauma system plan
- Hospitals self-designate using terms like "Level II Trauma Center" without verification (p. 15)
- 97 acute care hospitals, none objectively categorized by emergency capabilities
Trauma system planning should occur as part of the development of a state EMS plan." (p. 25)
Enabling legislation granting authority for comprehensive statewide trauma system development is mandatory." (p. 25)
3H. Medical Direction
(a) Direct quotes:Medical direction at the state level is provided by a State EMS Medical Director on a part-time basis. The support for this position has decreased in recent years." (p. 21)
Currently much of his responsibility involves the proctoring and evaluation of state level advanced skills examinations. This level of activity seems to prevent his involvement in policy activities of the OEMS." (p. 21)
There appears to be no job description outlining the roles and responsibilities for this position." (p. 21)
The majority of medical direction activities throughout the Commonwealth are unfunded by the EMS systems." (p. 21)
There are no qualifications or standards established for medical directors at any level and no consistent training for medical directors." (p. 22)
There currently is no provision for medical direction for first responders or Basic EMTs throughout the Commonwealth. Additionally, there is generally no medical direction for the activities of emergency medical dispatchers." (p. 22)(b) Specific data points:
- State EMS Medical Director is part-time
- No job description for the state medical director position
- No qualifications or standards for medical directors at any level
- No medical direction for first responders, BLS EMTs, or dispatchers
- Medical direction compensation: largely unfunded by EMS systems; some costs absorbed by hospitals/medical groups "by default"
- 5 Regional Medical Directors with varying roles
Basic EMTs, First Responders and EMS Dispatchers should be provided with medical direction.
OEMS should reassess the focus of activities of the State EMS Medical Director.
Establish a state plan for medical direction throughout the Commonwealth.
3I. Communications and Infrastructure
(a) Direct quotes:Basic 9-1-1 services cover 42% of Massachusetts' population. Enhanced 9-1-1 is being introduced." (p. 17)
The C-MED (Central Emergency Medical Direction) system covers most, but not all of the state. The equipment is approaching the end of its useful life. It is no longer supported by the manufacturer, so continuing maintenance is a concern." (p. 17)
There is limited ability for the C-MEDs to communicate with one another, and mass casualty incident (MCI) or disaster communications and mutual aid plans appear not to be well coordinated between regions." (p. 17)
There is no one identified in the state office with responsibility for communications coordination and planning." (p. 17)
Emergency medical dispatching, including post-dispatch instructions, does not appear to have been introduced outside metropolitan Boston." (p. 17)(b) Specific data points:
- 42% of population covered by basic 9-1-1
- Enhanced 9-1-1 under development with comprehensive enabling legislation, funding mechanism, and implementation structure
- C-MED system equipment reaching end of life, no longer manufacturer-supported
- System relies on leased telephone lines (adding cost) rather than microwave links
- No statewide EMD (emergency medical dispatch) outside Boston
- No communications coordinator at OEMS
- Number of PSAPs/dispatch centers: not documented
An updated communications plan needs to be developed by a committee of the EMS Advisory Board.
Emergency Medical Dispatching should be implemented as soon as practical throughout the Commonwealth, with particular emphasis on early implementation in rural areas with the longest response times.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
N/A — This is an initial assessment, not a reassessment.SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization of the EMS system:The TAT adopts a respectful but candid tone. The Introduction commends perseverance while identifying fundamental structural deficiencies:
The Massachusetts Office of Emergency Medical Services staff, the regional councils, and the providers throughout the Commonwealth should be commended for their perseverance through these difficult times." (p. 5)
Despite the constraints imposed on the system, a strong ambulance regulatory program, a regional council system, five trauma centers, and an outstanding medevac system have been maintained and development of an enhanced 9-1-1 system is underway." (p. 5)
This report was developed with the understanding that the citizens of Massachusetts deserve an integrated and comprehensive statewide EMS system in order to assure excellent patient outcomes." (p. 5)Structural barriers identified:
The report identifies multiple structural barriers as opposed to mere implementation or resource barriers:
- Absence of a statewide EMS plan
- Enabling legislation that does not reference medical direction standards, trauma systems, data collection, or state EMS planning authority (p. 6)
- No dedicated funding mechanism at either state or local level
- No job description, qualifications, or standards for medical directors
- No statutory QI confidentiality protections
- No enabling legislation for trauma system development
- Lead agency role is ambiguous and under-defined in law
The report is situated within NHTSA's highway safety/transportation framework. The Background section states:
NHTSA has determined that it can best use its limited resources if its efforts are focused on assisting states with the development of integrated emergency medical services programs that include comprehensive systems of trauma care." (p. 1)
NHTSA has developed a Technical Assistance Team (TAT) approach that permits states to utilize highway safety funds to support the technical evaluation of existing and proposed emergency medical services programs." (p. 1)
The EMS system itself is described using healthcare-oriented language ("patient outcomes," "patient care," "medical practice as delegated by physicians"), but the assessment mechanism and funding framework are explicitly transportation-based.
Federal funding mechanisms referenced:- NHTSA Section 402 funds — approximately $50,000/year since mid-1980s from Governor's Highway Safety Office (p. 6–7)
- Federal Preventive Health and Health Services Block Grant — $1,000,000 total ($500K OEMS operations + $500K regional councils) (p. 6–7)
- Categorical EMS grants — referenced as historical (late 1970s), now discontinued (p. 7)
- Maternal and Child Health Block Grant — referenced for injury prevention funding (p. 19)
- CDC funding — referenced for injury prevention (p. 19)
- NHTSA 402 Program — referenced again for injury prevention (p. 19)
- EMS for Children (EMSC) state grants — noted as pending opportunity (p. 19)
- NHTSA specialized training funding — >$300,000 since 1986 (p. 11)
- Strong ambulance regulatory/inspection program (commended multiple times)
- First responder training requirement (all firefighters, law enforcement, lifeguards required to obtain minimum training) — given "special recognition" (p. 11)
- EMT-D (defibrillation) program — described as research-based and laudable (p. 11)
- Medevac system — described as "outstanding" (p. 5)
- Commitment to Enhanced 9-1-1 development — "commended" (p. 17)
- Chain of Survival/citizen CPR emphasis
- Perseverance of OEMS staff, regions, and providers through fiscal adversity
- No statewide EMS plan
- No dedicated funding mechanism
- Enabling legislation that is outdated and does not cover key EMS system components
- No statewide trauma system, no enabling legislation, no registry
- No uniform data collection or evaluation capability
- Part-time, under-resourced state medical director consumed by testing duties
- Aging C-MED communications infrastructure
- Limited 9-1-1 coverage (42%)
- OEMS consumed by regulatory/enforcement activities with no capacity for system leadership and policy development
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. Biblical and philosophical framing. The TAT opens the Introduction with a Proverbs citation ("Where there is no vision, the people perish" — Proverbs 29:18) and closes with a reference to the Boston Common's foundation principles ("Learning, Religion, and Industry"). This rhetorical framing is distinctive among NHTSA assessment reports.
2. OEMS resource allocation paradox. The TAT identifies a structural paradox: the majority of OEMS staff time is dedicated to ambulance inspection and enforcement — the one well-functioning program — while system leadership, planning, and policy development go unaddressed:
It is striking that a large portion of the staff are focused on regulatory activities, with little opportunity to focus on policy development and system leadership." (p. 10)
3. Self-designation without verification. Hospitals are using trauma center level designations (e.g., "Level II Trauma Center") without any state verification process or evidence of meeting national standards (p. 15). This is identified as misleading.
4. Unfunded medical direction. The report documents that physician medical direction of EMS is structurally unfunded — costs are absorbed "by default" by hospitals and medical groups, not by EMS systems (p. 21). This is characterized as unsustainable.
5. No medical direction for BLS providers or dispatchers. At the time of assessment, the majority of the provider workforce (12,258 EMT-Basics plus first responders and dispatchers) operated without any formal medical direction, protocols, or standard of care (p. 22).
6. Prop 2½ cited as external constraint. The report identifies Massachusetts' property tax cap (Proposition 2½) as an external factor constraining trauma system development (p. 25), reflecting the intersection of state fiscal policy with EMS system capacity.
7. C-MED system obsolescence. The statewide medical communication system equipment is described as no longer supported by its manufacturer, relying on leased telephone lines rather than microwave links, with limited inter-regional communication capability (p. 17).
8. Absence of statutory QI protections. There is no statutory mechanism to ensure confidentiality and nondiscoverability of quality improvement activities in EMS (p. 27), creating a barrier to participation in evaluation processes.
9. Violence prevention as a model. The TAT cites the successful legislative championing of a violence prevention program as evidence that EMS could similarly attract legislative support with "broad public support and zealous leadership" (p. 8).
10. Helicopter underutilization concern. The report notes that varying regional policies and community hospital philosophies may lead to underutilization of air ambulance services (p. 13), and that there is no mechanism to investigate cases where helicopter transport may have been indicated but was not requested (p. 27).
Analysis extracted: February 2026. Source document: Commonwealth of Massachusetts, An Assessment of Emergency Medical Services, NHTSA Technical Assistance Team, March 17–19, 1992.
Michigan — 2 Reports
Full Analysis
Michigan 2007 NHTSA EMS Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Michigan
- Report type: Reassessment
- Date of site visit: May 15–17, 2007
- Year of publication: 2007
- Prior assessment year: 1991
- TAT members:
- Susan D. McHenry (EMS Specialist, NHTSA — served as NHTSA facilitator)
- Stuart A. Reynolds, MD, FACS (General Surgeon, Northern Montana Hospital; Chair, Montana EMS Advisory Council)
- Ritu Sahni, MD, MPH, FACEP (Associate Professor of Emergency Medicine, Oregon Health Science University; Medical Director, Oregon State EMS Office)
- Joseph W. Schmider (EMS Director, PA Department of Health Emergency Medical Services Bureau)
- Jolene R. Whitney, MPA (Assistant Director, Utah Bureau of Emergency Medical Services)
- NHTSA facilitator: Susan D. McHenry, EMS Specialist, NHTSA
- Number of presenters/briefings: Over 25 presenters from the State of Michigan (p. 5)
- Requesting agency: Michigan Department of Community Health, in concert with the Michigan Office of Highway Safety Planning (p. 4)
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not documented in this report. No state population figure is cited.
- Geographic characteristics: The report references the Upper Peninsula and "upper, Lower Peninsula" as largely underserved areas (p. 18). The state has 83 counties (p. 19). Facilities are "widely dispersed in the rural Upper Peninsula and Upper Lower Peninsula and more closely distributed in the southern areas of the state, particularly in the densely populated southeast" (p. 19).
- Number of counties/jurisdictions: 83 counties (p. 19)
- EMS system overview:
- Governance structure: The state uses a decentralized model with 65 Medical Control Authorities (MCAs) that serve as a "support arm of the EMS Office" providing local leadership and direction (p. 10). MCAs are staffed largely by volunteers and operated by boards consisting of hospital representation (pp. 10, 25). The EMS Coordinating Committee (EMSCC) and its QA Subcommittee provide state-level medical oversight functions (p. 25). 8 Regional planning districts exist (p. 11).
- Number of agencies/providers: 8,450 Medical First Responders; 11,070 EMTs; 1,200 EMT Specialists; 7,500 Paramedics; 930 Instructor Coordinators (p. 15). 181 licensed health care facilities, 140 licensed for Emergency Department care, 34 Critical Access Hospitals (p. 19). Approximately 10 Level I, 9 Level II, and 1 Level III ACS-verified trauma hospitals (p. 29).
- Notable demographic or socioeconomic factors cited: The report references a "drastic economic downturn experienced by the state in recent years" (p. 17), noting that at least 3 areas of the state have discontinued EMS service (p. 17). Michigan sustains about 5,200 deaths due to trauma per year (p. 28).
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:Without a current State EMS Plan there is no identified ambulance placement or response unit strategy that is based on patient need." (p. 17–18)
date, there has been no real comprehensive needs assessment to determine the level of service remaining unfulfilled." (p. 8)
Following the previous assessment, a plan was created in 2001 and has not yet been updated." (p. 32)(b) Specific data points: A state EMS plan was created in 2001 (p. 32) — one update since the 1991 assessment. The plan had not been updated as of 2007. The draft State Trauma Plan dates from 2004 (p. 23). (c) Report characterization: The TAT characterizes the existence of a 2001 plan as a positive step from the 1991 assessment but notes it is outdated and has not been updated. The absence of a current plan is linked to the inability to assess service needs, placement strategy, and resource utilization. (d) Priority recommendation: Yes (bolded):
Develop and implement a process to review and update the State EMS plan at least once every five years." (p. 13)
Continue work to implement the recommendations of the 1991 assessment, in particular the review and renewal of a State EMS plan including a component on transportation." (p. 18)
3B. Funding and Financial Sustainability
(a) Direct quotes:Other than licensure fees, there is no dedicated state funding supporting EMS, and the Office is overly dependent on Federal grant programs. As the Federal dollars continue to be reduced, it is important to understand the concern for State support is real." (p. 10)
Now is a time of struggle in Michigan, recent economic downturns present an interesting opportunity for lawmakers and leaders to solve financial woes present in the current government administration. To this end, the State EMS Office and the EMS System face uncertainty as to their future." (p. 8)
There is currently no funding generated for the MCAs and Medical Directors." (p. 25–26)
During lean financial times, it has been the extraordinary efforts of extraordinary individuals willing to carry the load, which has allowed EMS to make system wide improvements." (p. 8)
Begin now to consider future funding mechanisms to sustain these programs as Federal dollars are reduced or gone." (p. 34) — referring to emergency preparedness programs.(b) Specific data points: No specific dollar amounts, budget figures, or appropriation levels are cited. A proposed funding mechanism through the Crime Victim Commission for the trauma system is mentioned (p. 29), requiring legislative action. Licensure fees are the only identified dedicated state revenue for the EMS office (p. 10). (c) Report characterization: The TAT characterizes funding as a critical vulnerability. The dependency on federal grants, the absence of dedicated state funding, and the economic downturn create compounding risk. The TAT frames this explicitly as a matter requiring legislative and gubernatorial action: "Now is the time for the Legislature and Governor to fully fund and staff the EMS Office" (p. 8). (d) Priority recommendation: Yes (bolded):
Obtain dedicated funding to support the Michigan EMS office and the continued development of the State Trauma system." (p. 10)
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:it is very clear the EMS Office is grossly understaffed." (p. 12)
The current staff, dedicated to the profession, is simply too overtaxed to carry out all the functions and duties of the office." (p. 12)
here is a 30% provider non-compliance rate in meeting the education requirements for re-licensure, in spite of the fact that the State's CE requirements are minimal. This statistic gave the team great cause for concern" (p. 15–16)
Currently there is no process in place to know if the number of licensed providers meets the needs of the System or how many providers are active within the State." (p. 15)
at least three areas of the state have discontinued service placing the population in grave danger." (p. 17)
Only in recent months have services begun to close and leave citizens without access to pre-hospital care." (p. 8)(b) Specific data points:
- 8,450 Medical First Responders; 11,070 EMTs; 1,200 EMT Specialists; 7,500 Paramedics; 930 Instructor Coordinators (p. 15)
- Total licensed/certified EMS personnel: approximately 29,150 (calculated from above)
- 30% provider non-compliance rate for continuing education requirements (p. 15–16)
- At least 3 areas of the state have discontinued EMS service (p. 17)
- The state EMS office itself is described as "grossly understaffed" (p. 12)
Increase staffing in the EMS office to allow for the office to meet the legislative requirements of ensuring a quality, effective system of emergency medical services and to centralize the EMS functions of the EMS Office." (p. 10)
Staff the EMS Office with sufficient state employees to implement the provisions of P.A 378, Part 209 and the administrative regulations. Staffing should include a full complement of administrative personnel and a State EMS/Trauma Medical Director." (p. 13)
3D. Essential Service Designation
(a) Direct quotes:here is a need for full commitment from state leadership to focus on this essential service." (p. 10)(b) Specific data points: The phrase "essential service" appears once (p. 10), used by the TAT to describe EMS rather than citing a statutory designation. (c) Report characterization: The TAT uses "essential service" language descriptively but does not document whether Michigan has a legal essential service designation for EMS. No statutory framework for essential service designation is discussed. (d) Priority recommendation: The report does not recommend essential service designation as such. The recommendation to "Pursue legislation, which will require counties or a collaboration of counties within a region or MCA to insure the provision of pre-hospital emergency medical care by a transporting unit" (p. 18) addresses a related concept — mandating that counties ensure EMS availability — without using the essential service framework.
3E. Regulatory Fragmentation
(a) Direct quotes:Michigan has maintained a decentralized approach to the management of many of the administrative functions of the EMS office." (p. 12)
The EMS Office continues to contract with private third party vendors to carry out many of the administrative duties of the office including but not limited to the inspection of ambulance agencies and the testing of student candidates for certification and licensure." (p. 12)
he State has delegated a number of functions to contractors (e.g. ambulance and education program inspections), but there was no evidence given of any evaluation of the performance of those contractors." (p. 32)
There was an identified need for evaluation of MCA's to ensure more uniformity throughout the State." (p. 10)
here is a wide variety of functionality to the MCAs and the State has no evaluation process to determine if the MCAs are meeting their statutory requirements." (p. 25–26)
here is a conflict between the state EMS statute and the 9-1-1 legislation." (p. 21)
MCAs have the responsibility 'to assure the appropriate dispatching of life support agencies.' The 9-1-1 legislation duplicates this responsibility to each 9-1-1 center bypassing medical oversight by the MCAs." (p. 21–22)
Air medical transport agencies do not participate in the MCA process and air medical protocols do not have to be approved by the State." (p. 25)(b) Specific data points:
- 65 MCAs with varying levels of functionality (pp. 10, 25–26)
- 8 Regional planning districts/Trauma Regions (p. 11)
- Third-party contractors perform ambulance inspections and candidate testing (p. 12)
- No evaluation of contractor performance has occurred (p. 32)
- No evaluation of MCA statutory compliance has occurred (p. 25–26)
- Statutory conflict between EMS law and 9-1-1 legislation on dispatch authority (p. 21)
- Air medical agencies exempt from MCA process and state protocol approval (p. 25)
Develop an evaluation process of the Medical Control Authorities to ensure statutory compliance and greater uniformity across the State." (p. 10)
State employees must carry out all the statutory functions of the State EMS Office." (p. 13)
The MCAs should continue consolidation of protocols and requirements so the same protocols, standards, and destination protocols exist throughout each Region." (p. 27)
3F. Data and Evaluation Systems
(a) Direct quotes:There have been relatively unsuccessful attempts to create a statewide data set." (p. 32)
There is currently an RFP in process to create a statewide EMS Information System, which will be NEMSIS-Gold compliant. All agencies shall provide data to this system." (p. 32)
No QI data is collected at the state level." (p. 32)
Although the hospitals operate the MCAs, there persists frustration from the providers and Medical Directors on the lack of outcome data available from the hospitals." (p. 31–32)
here is no State guidance as to what those indicators are" (p. 26) — referring to optimal performance indicators.
The total lack of data on the specialty courses, tracking of courses and how many providers are taking these courses is problematic for future planning" (p. 15)(b) Specific data points:
- The state is pursuing a NEMSIS-Gold compliant system (p. 32)
- No statewide trauma registry exists, though some ACS-verified hospitals participate in a voluntary registry (p. 32)
- No QI data collected at state level (p. 32)
- No linkage between prehospital data and hospital outcomes (p. 32)
- The previous assessment (1991) recommended statewide data collection; it remains unaccomplished 16 years later (p. 26)
Continue with implementation of the NEMSIS-Gold compliant, statewide EMS Information System. Strongly consider the ability to track provider licensure, agency licensure and patient care reporting into one system." (p. 32)
3G. Trauma System Status
(a) Direct quotes:here does not yet exist a Michigan Trauma System per se, as none of the designated components described have been put in place except for the Trauma Advisory Committee. There is no trauma system registry, no instituted designation process, no statewide trauma PI, no Trauma Medical Director and no trauma specific prevention program." (p. 29)
The recent passage of trauma legislation provides a bright spot in the future of Michigan's EMS System." (p. 8)
During the last seven years there has been an acceleration in trauma system related activities; a Governor's Commission was appointed; a report written; trauma enabling legislation passed, creating a State Trauma Advisory Committee (STAC)." (p. 28–29)
a funding mechanism through the Crime Victim Commission has been proposed and a tentative agreement has been reached, although legislative action will be required." (p. 29)(b) Specific data points:
- Approximately 10 Level I, 9 Level II, and 1 Level III ACS-verified hospitals (p. 29)
- 5,200 trauma deaths per year in Michigan (p. 28)
- Trauma enabling legislation passed, creating the STAC (p. 28–29)
- Draft Trauma System Plan and draft Administrative Rules produced (p. 28–29)
- No statewide trauma registry exists (p. 29)
- No trauma designation process yet instituted (p. 29)
- No Trauma Medical Director (p. 29)
- Proposed funding through Crime Victim Commission (p. 29)
- 8 Regional Trauma Networks established (pp. 11, 30)
3H. Medical Direction
(a) Direct quotes:There is no State EMS/Trauma Medical Director." (p. 25)
here is also a desperate need for a State level EMS Medical Director that might also serve as the medical director for a budding Trauma System." (p. 12)
On-line medical control (OLMC) appears to be an area of concern. Some MCAs have training and guidelines as to who may provide OLMC. In other MCAs, there are no guidelines. The State has no standard qualification as to who may provide OLMC and what training is required." (p. 26)
An MCA may adopt the State Model Protocols or develop its own set of protocols" (p. 25) — resulting in protocol variation across the state.
Some providers expressed frustration over protocol variation and recommended there be a single set of statewide protocols." (p. 25)
Although MCAs are required by statute to perform quality improvement (QI), it is unknown by the State what QI processes are performed by the individual MCAs." (p. 26)
MCAs have been placed in the untenable position of statutory responsibility with no authority." (p. 26) — regarding dispatch medical oversight.(b) Specific data points:
- 65 MCAs with varying protocols, QI processes, and medical direction quality (pp. 25–26)
- No state EMS/Trauma Medical Director (p. 25)
- No funding for MCAs or Medical Directors (p. 25–26)
- State Model Protocols exist (authored by EMSCC QA Subcommittee) but adoption is voluntary at MCA level (p. 25)
- Air medical protocols not subject to state approval (p. 25)
- No standard qualifications for on-line medical control providers (p. 26)
Staff the EMS Office with sufficient state employees...Staffing should include...a State EMS/Trauma Medical Director." (p. 13)
The State should create and fund the position of State EMS/Trauma Medical Director. This position would provide medical oversight to the office. In addition, the EMS MD would provide oversight guidance, including QI priorities directly to the MCAs. The MCAs should be accountable to the State EMS/Trauma Medical Director." (p. 26–27)
The State should create and fund the position of State EMS/Trauma Medical Director who would set the plan and priorities for a statewide QI system." (p. 33)
3I. Communications and Infrastructure
(a) Direct quotes:here is a conflict between the state EMS statute and the 9-1-1 legislation." (p. 21)
Emergency Medical Dispatch is locally controlled with no State governance." (p. 21)
here continues to be no state minimum training standard for emergency medical dispatchers. There is also no state minimum requirement for medical priority dispatch systems." (p. 22)
Many dispatch centers use vendor driven medical priority dispatch systems but without medical oversight." (p. 22)
Tiered dispatching protocols including air medical activation are determined locally rather than using standardized statewide protocols." (p. 22)
Performance Improvement for EMS dispatch is inconsistent with little case review and sparse medical oversight." (p. 22)(b) Specific data points:
- E-9-1-1 served 75% of population in 1991; now available in all but 1 county (p. 21)
- The state maintains an FCC license covering 2 frequencies for EMS providers: 155.355 (on-scene coordination) and 155.340 (ambulance-to-hospital) (p. 22)
- Every ambulance and hospital in the state is equipped for the 155.340 frequency (p. 22)
- Statewide 800 MHz system available through the State Police (p. 22)
- MEDCOM communications plan updated in 2006 (p. 21)
- No count of PSAPs or dispatch centers provided
- No state dispatcher training or certification standard (p. 22)
Modify the 9-1-1 legislation so the MCAs have the authority for direct medical oversight for EMS dispatching." (p. 22)
Establish administrative rules, to support mandatory and uniform emergency medical dispatcher certification and education for all EMS dispatch centers." (p. 22)
Establish administrative rules, which require dispatch centers to utilize medical priority dispatch systems with pre-arrival instructions, which have been reviewed and approved by the State." (p. 22)
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (Reassessment)
The report measures progress since the 1991 assessment. No formal numbered tracking is provided. Progress is characterized narratively within each section.
Overall characterization of progress since 1991:Since the 1991 initial assessment, there have been great strides in the provision of ALS and LALS services across Michigan." (p. 8)
While important cornerstones have been laid, much work remains to complete the framework of a solvent, comprehensive EMS System." (p. 8)
The TAT's tone regarding 1991 progress is more measured than the Oregon or Kansas reassessments — acknowledging meaningful forward movement while identifying substantial remaining gaps.
Documented as completed or substantially improved:- Comprehensive enabling legislation (Part 209 of P.A. 378) passed (p. 10)
- Administrative rules enacted in May 2004 (p. 10)
- E-9-1-1 expanded from 75% to all but 1 county (p. 21)
- MEDCOM communications plan updated (2006) (p. 21)
- Trauma enabling legislation passed (p. 28–29)
- ACS-verified trauma hospitals increased substantially (p. 29)
- State EMS plan created in 2001 (first plan since 1991) (p. 32)
- Emergency preparedness — characterized as a national model (p. 34)
- MCAs established providing local medical oversight structure (p. 10)
- Expansion of ALS and LALS services statewide (p. 8)
- Prehospital DNR legislation passed and State Model Protocol implemented (p. 26)
- No State EMS/Trauma Medical Director (recommended 1991, still absent) (pp. 12, 25)
- No statewide data collection system (recommended 1991, RFP in process but not operational) (pp. 26, 32)
- State EMS plan not updated since 2001 (recommended every 5 years) (p. 32)
- No evaluation of MCAs for statutory compliance (pp. 10, 25–26)
- No evaluation of third-party contractor performance (p. 32)
- State EMS office still "grossly understaffed" (p. 12)
- No dedicated state funding for EMS (p. 10)
- No statewide trauma registry (p. 29, 32)
- Certificate of Need (CON) process not reinstated (p. 11)
- No comprehensive needs assessment conducted (p. 8)
- No dispatcher training/certification standards (p. 22)
- Protocol variation across MCAs remains (p. 25)
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization:The tone of this report is constructive and encouraging, acknowledging genuine legislative and structural progress since 1991 while identifying critical unfinished work. The Introduction strikes a warmer and less critical tone than the Oregon or Kansas reassessments:
The 2007 NHTSA reassessment team is honored and grateful that you have invited us to your state and we hope your system continues to be strong and to it we pledge our support." (p. 8)
During lean financial times, it has been the extraordinary efforts of extraordinary individuals willing to carry the load, which has allowed EMS to make system wide improvements." (p. 8)
The grassroots support for the State EMS Office is overwhelming." (p. 8)
The TAT's central message is that legislative foundations have been laid (P.A. 378, trauma legislation) but implementation is stalled by inadequate funding and staffing:
While important cornerstones have been laid, much work remains to complete the framework of a solvent, comprehensive EMS System." (p. 8)
Now is the time for the Legislature and Governor to fully fund and staff the EMS Office and support the EMS and trauma care system." (p. 8)Structural barriers identified:
- No dedicated state funding — dependency on federal grants and licensure fees (p. 10)
- EMS office "grossly understaffed," unable to meet statutory obligations (p. 12)
- 65-MCA structure creating wide variability without state evaluation or oversight (pp. 10, 25–26)
- Statutory conflict between EMS law and 9-1-1 legislation on dispatch authority (p. 21)
- Third-party contractors performing core state functions without evaluation (p. 12, 32)
- Air medical agencies exempt from MCA and state protocol processes (p. 25)
- MCAs have statutory responsibility for dispatch without authority to enforce (p. 26)
- Economic downturn causing service closures (p. 17)
The report operates within the transportation framework. The reassessment was requested through the Michigan Office of Highway Safety Planning (p. 4). The Background references highway safety funds (p. 4) and the EMS Agenda for the Future's health management system vision (p. 4). Notably, the EMS office is located within the Michigan Department of Community Health (p. 4), which is a health department placement, and the TAT does not recommend relocation. The recommendations focus on strengthening the existing structure rather than repositioning EMS institutionally.
Federal funding references:Other than licensure fees, there is no dedicated state funding supporting EMS, and the Office is overly dependent on Federal grant programs. As the Federal dollars continue to be reduced, it is important to understand the concern for State support is real." (p. 10)
Begin now to consider future funding mechanisms to sustain these programs as Federal dollars are reduced or gone." (p. 34)
The Office of Highway Safety Planning is noted as supporting implementation of MI EMSIS (p. 32). No Section 402 funds are cited by name.
Greatest strengths (as identified by the TAT):he nation should again look to Michigan for innovation in the area of public health preparedness...the collaboration with EMS and other agencies in this area has provided Michigan with a preparedness model that should be the envy of the nation." (p. 34)
Comprehensive enabling legislation (P.A. 378, Part 209) and 2004 administrative rules (p. 10)
Trauma enabling legislation and acceleration of ACS verification (pp. 8, 28–29)
Statewide radio system with universal ambulance/hospital equipment on single frequency (p. 22)
MEDCOM communications plan (p. 21)
Staff dedication and grassroots support (p. 8)
EMS-C Committee becoming more active with permanent funding for coordinator (p. 26)Most critical challenges (as identified by the TAT):
- No dedicated state funding; federal grant dependency (p. 10)
- Grossly understaffed EMS office (p. 12)
- No State EMS/Trauma Medical Director (pp. 12, 25, 33)
- No statewide data system (p. 32)
- 65 unevaluated MCAs with wide variability (pp. 10, 25–26)
- Nascent trauma system with no operational components (p. 29)
- Service closures due to economic downturn (p. 17)
- 30% CE non-compliance rate (p. 15–16)
- No dispatcher training or certification standards (p. 22)
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. Emergency preparedness as national model
The TAT's characterization of Michigan's emergency preparedness program is strikingly positive:
he nation should again look to Michigan for innovation in the area of public health preparedness. Clearly, there has been much work with this area and the collaboration with EMS and other agencies in this area has provided Michigan with a preparedness model that should be the envy of the nation." (p. 34)
This is one of the strongest positive characterizations of any single component in the NHTSA assessment corpus, particularly notable given the critical findings across most other component areas.
2. Service closures documented as occurring
Only in recent months have services begun to close and leave citizens without access to pre-hospital care." (p. 8)
at least three areas of the state have discontinued service placing the population in grave danger." (p. 17)
The documentation of active service closures — described as leaving citizens "without access to pre-hospital care" and "in grave danger" — is a real-time finding of system failure rather than a projected risk. This connects to the broader economic downturn context.
3. 30% CE non-compliance rate
here is a 30% provider non-compliance rate in meeting the education requirements for re-licensure, in spite of the fact that the State's CE requirements are minimal." (p. 15–16)
A 30% non-compliance rate with minimal CE requirements is a significant data point. The TAT expresses "great cause for concern" and recommends it be included in a comprehensive education survey.
4. Unevaluated third-party contractors performing state functions
The Michigan model of outsourcing core state functions (ambulance inspections, candidate testing) to private contractors without any evaluation of their performance (p. 12, 32) is an unusual structural finding. The TAT recommends both centralizing these functions with state employees and, if contractors remain, requiring regular performance evaluation (pp. 13, 33).
5. Recommendation for county-level EMS mandates
Pursue legislation, which will require counties or a collaboration of counties within a region or MCA to insure the provision of pre-hospital emergency medical care by a transporting unit." (p. 18)
This recommendation — that counties be legally required to ensure EMS transportation availability — is a significant structural proposal. While not using the term "essential service," it proposes a legislative mandate that counties guarantee EMS coverage, which is functionally similar.
6. Trauma system: legislation passed but zero operational components
The Michigan trauma system represents an interesting case study: enabling legislation has passed, a State Trauma Advisory Committee exists, draft plans and rules have been produced, ACS verification has increased substantially, and a funding mechanism has been proposed — yet "there does not yet exist a Michigan Trauma System per se" (p. 29). This gap between legislative framework and operational implementation is a notable finding.
7. "Untenable position" of MCAs on dispatch
The TAT describes MCAs as being in an "untenable position of statutory responsibility with no authority" (p. 26) regarding dispatch medical oversight. The statutory conflict between EMS law (assigning dispatch responsibility to MCAs) and 9-1-1 legislation (assigning it to 9-1-1 centers) creates a structural impasse.
8. Air medical exemption from state oversight
Air medical transport agencies do not participate in the MCA process and air medical protocols do not have to be approved by the State." (p. 25)
The exemption of air medical agencies from both the MCA structure and state protocol approval is a regulatory gap. The TAT recommends consideration of "a single, statewide Air Medical MCA" (p. 27) — an innovative structural proposal.
9. TAT member from Oregon serving during Oregon's own reassessment period
Ritu Sahni, MD, is listed as Medical Director of the Oregon State EMS Office (p. 38), a position he held during and after Oregon's 2006 reassessment. His participation on the Michigan TAT one year later provides an interesting cross-pollination between the two state assessments.
10. The "Yoopers and Trolls" introduction
The Introduction's reference to "Yoopers and Trolls" (p. 8) — local terms for Upper and Lower Peninsula residents — along with mentions of Francis Ford Coppola, Steven Segal, and the Tigers and Lions, represents an unusually informal and personal opening for an NHTSA reassessment. This contrasts with the more dramatic/urgent introductions in the Oregon and Kansas reports and signals a TAT that felt more goodwill toward the system under review.
Analysis extracted by standardized framework. No editorial synthesis applied. All page references correspond to the PDF pagination of the source document.
Full Analysis
Michigan 2017 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Michigan
- Report type: Reassessment
- Date of site visit: March 28–30, 2017
- Year of publication: 2017
- Prior assessment year: 2007 (Introduction, p.8: "in the 10 years since the last assessment")
- TAT members:
- Steven A. Gienapp, MS, NRP
- Peter P. Taillac, MD, FACEP
- Kyle L. Thornton, MS, EMT-P
- P. Scott Winston, BS, EMT-P
- NHTSA facilitator: Susan McHenry, MS
- Executive support: Janice D. Simmons, BFA
- Number of presenters/briefings: Over 30 presenters over the first day and a half (Background, p.5)
- Requesting agency: Michigan Bureau of Emergency Medical Services, Trauma and Preparedness (BETP)
SECTION 2: STATE CONTEXT
- Population (as cited in report): "Nearly 10 million" (Introduction, p.8); "approximately ten million Michigan residents" (Human Resources, p.17)
- Geographic characteristics: "Wide variety of areas that range from the very rural to the highly urban, more than 3,000 miles of freshwater coast" (Introduction, p.8); two peninsulas; rural Michigan accounts for 19% of the population but 75% of the land mass (Facilities, p.25)
- Number of counties/jurisdictions: 83 counties; 61 Medical Control Authorities (MCAs) within 8 MCA regional networks; 8 EMS and trauma regions
- EMS system overview:
- Two divisions: Division of Emergency Preparedness & Response; Division of EMS and Trauma
- State EMS Medical Director: Dr. William Fales (since October 2015), 0.32 FTE contracted position
- Over 28,000 licensed EMS personnel
- ~800 licensed Life Support Agencies (LSAs): 51% Medical First Responder, 27% ALS, 21% BLS, 1% Limited ALS
- Over 2,400 life support vehicles
- 61 MCAs (administered by "participating hospitals") serving 83 counties
- 8 EMS/trauma regions
- 9 rotary wing services (3 also offer fixed wing)
- 132 state-licensed acute care hospitals (34 Critical Access Hospitals)
- 7 free-standing emergency departments
- Up to 50% of EMS workforce receives less than full-time compensation (paid-on-call/volunteer)
- Emergency Medical Services Coordination Committee (EMSCC): statutory, large, appointed by MDHHS Director; includes ex-officio State Senator and Representative
- Subcommittees: Statewide Trauma Advisory Committee (STAC), Committee on Pediatric Emergency Medicine (CoPEM), Quality Assurance Task Force (QATF), Ambulance Operations Subcommittee (13 members)
- 4 EMS licensure levels: MFR, EMT, AEMT, Paramedic
- 5 Regional Coordinators + 1 floater (contracted through Michigan Public Health Institute)
- Notable demographic or socioeconomic factors cited: "Number two state in the country for human trafficking" (PI&E, p.30). Two-thirds of infant deaths (~150/year) are preventable (PI&E, p.30). Top injury prevention priorities: motor vehicle occupants (53.1%), elderly falls (38.1%), substance abuse (26.5%) (PI&E, p.30).
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:The recent strategic planning effort is an excellent example of the BETP seeking input from stakeholders and using that information to develop future goals." (Resource Management, p.14)
The working trauma system plan was drafted in 2004. It is out of date." (Trauma Systems, p.38)(b) Data points: A State EMS Plan (2017–2021) is currently under development. Trauma system plan drafted 2004 — out of date. Recent revision of trauma system rules awaiting legislative approval. (c) TAT characterization: Strategic planning praised; trauma plan acknowledged as outdated. (d) Priority recommendation: Include comprehensive PI&E Plan for EMS and Trauma as a component of the strategic State EMS Plan (2017–2021). Revise the Trauma System Plan.
3B. Funding and Financial Sustainability
(a) Direct quotes:The FY 2017 budget for the Division of EMS and Trauma was $6,565,600, which includes state funds and federal grants. However, over half of this funding, the portion obtained from the Crime Victims Services Fund ($3,500,000), is at risk. Approximately one half of this funding is scheduled to 'sunset' in 2018, which would be devastating." (Regulation and Policy, p.11)(b) Data points:
- FY 2017 Division of EMS and Trauma budget: $6,565,600 (state funds + federal grants)
- Crime Victims Services Fund contribution: $3,500,000 (over half of total budget) — scheduled to sunset in 2018
- Bureau partially funded by licensure fee revenue
- OHSP previously funded MI-EMSIS and trauma registry implementation — "this specific financial support is no longer available"
- Trauma system funding not appropriated until 2012 despite rules approved in 2008
- EMS Week activities: no promotion due to "funding and staff resources"
- HRSA grant funded AED placement (356 AEDs in rural areas)
- FLEX grant funded EMS Leadership Academy
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:There is a concern regarding the waning availability of individuals willing to volunteer for EMS service." (Human Resources, p.18)
It is unlikely that volunteer models for EMS delivery are sustainable in the long term." (Resource Management, p.14)
One area of caregiver licensure in Michigan is significantly lacking; the emergency medical dispatcher (EMD)." (Human Resources, p.18)(b) Data points:
- Over 28,000 licensed EMS personnel
- ~800 LSAs; over 2,400 life support vehicles
- Up to 50% of EMS workforce less than full-time (paid-on-call/volunteer)
- 4 licensure levels: MFR, EMT, AEMT, Paramedic
- CAAHEP accreditation for paramedic programs underway; all programs expected to achieve CoAEMSP letter of review or CAAHEP accreditation by January 1, 2018
- Livingston County HS EMT program: works with 5 high schools offering EMT to seniors; discussion of "13th year" option for paramedic
- EMS Leadership Academy: 70 rural LSAs trained over 4 years (FLEX grant funded)
- BETP partnering with Office of Rural Health and Michigan Rural EMS Network (MI REMS) for recruitment/retention
- Criminal background checks limited to online, in-state source only — no biometric NCIC
- Rules not updated in at least 10 years
- EMD not licensed or certified by state
- BETP unable to determine number of EMS providers affiliated with each LSA
- Electronic licensure system delayed
- No formal investigatory training for staff conducting licensure investigations
- Legislature should establish EMD licensure
- Legislature should authorize NCIC biometric criminal background check program
- BETP should begin comprehensive rule revision
- BETP should complete investigative/licensure action process review
3D. Essential Service Designation
Not documented in this report. The term "essential service" does not appear.3E. Regulatory Fragmentation
(a) Direct quotes:There are 61 MCAs that fall within the borders of eight MCA regional networks in Michigan." (Transportation, p.22)
There is still wide variability in the accountability and performance of individual MCAs." (Evaluation, p.41)
Much, if not all, of the rules utilized by the BETP has not been updated in at least 10 years." (Human Resources, p.19)(b) Data points:
- 61 MCAs administered by "participating hospitals" across 83 counties within 8 regions
- MCAs develop protocols; state approves
- Wide variability in MCA accountability and performance
- BETP has led efforts to ensure MCAs performing statutory duties
- 5 Regional Coordinators + 1 floater (contracted, not state employees)
- Administrative rules not updated since 2004 (EMS-LSA rules) or at least 10 years generally
- EMS-LSA and Medical Control Rules: 2004 vintage
- Michigan State Protocols last fully updated 2012
- Inconsistency in inspection practices by Regional Coordinators reported
- Michigan Public Service Commission (MPSC) regulates PSAP training — not aligned with EMS dispatch needs
- Hospitals self-identify as stroke/STEMI centers — no state designation
- No requirement for non-trauma designated hospitals to submit trauma data
- No rule to regulate proliferation of high-level trauma centers in urban areas
- Inter-facility critical care transfer: no continuing education, clinical experience, or internship requirements for paramedics
- Comprehensive review and revision of administrative regulations
- Develop stroke and STEMI designation processes
- Develop rule to regulate proliferation of high-level trauma centers (ACS Needs Based Assessment tool)
- Continue MCA statutory duty evaluation
3F. Data and Evaluation Systems
(a) Direct quotes:Since the 2007 NHTSA Reassessment, the state has made substantial improvements in its data systems and PI programs." (Evaluation, p.41)
There is currently no linkage between the EMS and trauma registries." (Evaluation, p.41)(b) Data points:
- MI-EMSIS: NEMSIS-compliant EMS data system; 88% of transporting agencies submitting data; transitioning to NEMSIS 3.4
- State trauma registry: receiving records from ~85% of Michigan hospitals
- Both registries compatible with NTDBS and NEMSIS standards
- No linkage between EMS and trauma registries
- No linkage to crash data
- "No significant data quality issues reported" for EMS data
- Non-designated hospitals not required to submit trauma data
- 69 newly trained in-state trauma center reviewers
- Epidemiologist position vacant
- OHSP funding for data systems no longer available
- Data not yet used for field triage/transport decision analysis statewide
- Several PI initiatives completed: lights-and-sirens safety evaluation; EMT epinephrine pilot
- BETP working with external vendor for licensure data management
- Cannot determine provider-to-agency affiliations
- Trauma registry trending "limited number of indicators" — "scratches the surface"
- Registrars and system new; inter-rater reliability work needed
- Bureau recently hired CQI Coordinator
- Fill vacant epidemiologist position
- Link EMS and trauma registries through unique identifiers
- Link trauma registry with crash data
- Develop statewide trauma PI plan with extractable performance indicators
- Consider requiring non-designated hospitals to submit trauma data
- Develop stroke/STEMI designation with reporting requirements
3G. Trauma System Status
(a) Direct quotes:Michigan is obviously proud of its budding inclusive state trauma system. Even with the delay in appropriated funding until 2012, it has moved forward with focus and clarity." (Trauma Systems, p.37)
There is no rule in place to assist the State in determining the need for future Level 1 or 2 trauma centers. Allowing unfettered high-level trauma center designation risks diluting the experience of each center with a resultant decrease in the quality of care provided." (Evaluation, p.41)(b) Data points:
- ACS-verified Level I and II trauma centers in state for over 20 years
- Trauma Administrative Rules approved by legislature 2008; funding not appropriated until 2012
- Designation criteria finalized 2015
- Currently designated: 8 Level I, 23 Level II, 9 Level III, 1 Level IV
- Level I and II verified by ACS; Level III option for ACS or in-state review; Level IV by in-state reviewers
- 69 newly trained in-state reviewers for Level IV
- Division confident nearly all undesignated hospitals will seek designation
- 7 Level I/II trauma centers also ACS-verified pediatric trauma centers
- 6 burn centers (3 ACS burn-verified) — not state designated
- No state designation for pediatric, cardiac, or stroke facilities
- CDC Field Triage Guidelines adopted for trauma triage
- Trauma System Plan drafted 2004 — out of date; revised rules awaiting legislative approval
- Trauma registry data from ~85% of hospitals; limited indicators trending
- No analysis of field triage/transport decisions performed statewide
- Inter-facility critical care transfer deficiencies not addressed
- No requirement for non-designated hospitals to submit data
- Revise Trauma System Plan
- Develop more robust registry quality indicators
- Address critical care inter-facility transfer quality/training
- Consider requiring non-designated hospitals to submit trauma data
- Develop rule to regulate proliferation of high-level trauma centers using ACS Needs Based Assessment tool
3H. Medical Direction
(a) Direct quotes:The State Medical Director position is a fairly new position, existing only since 2015." (Regulation and Policy, p.10)
There is no consistent training or standards for new MCA medical directors. The responsibilities, accountability, and reimbursement of these medical directors appears to vary widely between MCAs." (Medical Direction, p.35)
Given the depth and breadth of the position of State EMS Medical Director and the associated time involvement, consider an increase in the position above the current 0.32 FTE... The majority of states support a 0.5 FTE for their State EMS Medical Directors, most of which have smaller populations than Michigan." (Medical Direction, p.36)(b) Data points:
- State EMS Medical Director: Dr. William Fales, since October 2015; 0.32 FTE contracted
- Supports both Division of Emergency Preparedness & Response and Division of EMS & Trauma
- Described as "very active" and "well thought of"
- Initiated several PI projects; increased protocol consistency across regions
- Michigan State Protocols: last fully updated 2012; currently under review
- 61 MCAs with medical directors — no standardized job description, training, or reimbursement model
- MCAs have adopted state protocols with "some regional variations"
- Several regions adopted uniform "drug boxes"
- PSROs established in each MCA for PI purposes
- Regional PSROs focused on trauma PI — could expand to other EMS PI
- 2007 recommendation for pediatric emergency physician on EMSCC not implemented
- CoPEM and EMS-C program provide pediatric input to EMSCC instead
- Increase State EMS Medical Director FTE above 0.32 (national comparator: 0.5 FTE)
- Update full set of Michigan State EMS Protocols using NASEMSO Model EMS Clinical Guidelines
- Develop standardized MCA medical director job description, training curriculum, and reimbursement model
- Expand regional PSROs beyond trauma to all EMS PI
3I. Communications and Infrastructure
(a) Direct quotes:There is no requirement that those answering calls for emergency medical assistance receive Emergency Medical Dispatch (EMD) training and certification. This means that Michigan has no assurances that persons requesting EMS will receive consistent pre-arrival instructions." (Communications, p.29)(b) Data points:
- Statewide 800 MHz system accessible to public safety agencies/partners
- Private entities with public safety role allowed to participate — "commendable"
- Smart911 software: legislature appropriated funding for all PSAPs; over 30 counties upgraded
- 2012 requirement: tele-communicators in primary PSAPs must complete minimum training (Michigan Public Service Commission)
- Training requirement applies to primary PSAPs only — not secondary facilities
- No EMD training or certification required for EMS dispatchers
- No consistent pre-arrival instructions statewide
- Wide variation in local communications systems
- BETP has published a communications plan
- Public safety broadband recommended for rural areas
- MPSC should adopt administrative rules requiring EMD certification for EMS dispatch
- Continue incentivizing statewide 800 MHz adoption while maintaining legacy redundancy
3J. Preparedness
(a) Direct quotes:The team agreed that Preparedness was a particularly strong capability within in the state and we commend the BETP for their efforts." (Preparedness, p.44)(b) Data points:
- Coalition approach since 2002 (bioterrorism funding)
- Healthcare Coalitions (HCCs) evolved from original coalitions; select MCAs as fiduciary agents; transitioning to independent 501(c)(3) organizations
- Michigan Emergency Drug Delivery and Resources Utilization Network (MEDDRUN): short-term solution between chemical/biological event and SNS release
- Basic and Advanced Disaster Life Support training provided to all provider types
- HAvBED system: tracks EMS and dialysis center resources
- Region 6: patient tracking system used routinely — identified as "best practice"
- Special pathogen response network protocols developed
- REPLICA adoption recommended for interstate licensure
- Division of Emergency Preparedness & Response co-located with Division of EMS & Trauma within BETP
- Highlight Region 6 patient tracking best practice
- Legislature should adopt REPLICA
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
This is a reassessment of the 2007 assessment (10-year interval).
It is clear that in the 10 years since the last assessment, Michigan has made tremendous strides in building its EMS and trauma system and the assessment team applauds your work." (Introduction, p.8)Key progress since 2007:
- Trauma Administrative Rules approved (2008); funding appropriated (2012); designation criteria finalized (2015)
- 41 trauma centers designated (8 Level I, 23 Level II, 9 Level III, 1 Level IV)
- 69 in-state trauma reviewers trained
- MI-EMSIS implemented (88% transporting agency compliance)
- State trauma registry implemented (~85% hospital compliance)
- State EMS Medical Director position created (2015)
- BETP "added significantly to its staff" over 10 years
- CDC Field Triage Guidelines adopted
- Michigan State Protocols adopted by MCAs with regional consistency improving
- Strategic planning effort initiated (State EMS Plan 2017–2021)
- DOSE safe sleep program: trained 1,000+ EMS providers, purchased 500+ Pack N Plays, contributed to record low infant sleep-related deaths in 2016
- 356 AEDs placed in rural areas (HRSA grant); 6 documented uses, 5 saves
- EMS Leadership Academy: 70 rural LSAs trained
- Ambulance child restraints distributed to all transport vehicles
- Smart911 rolling out statewide
- Preparedness programs commended
- MEDDRUN developed
- HCC structure evolved
- 2007 recommendation for pediatric physician on EMSCC: NOT implemented
- EMD certification: NOT established
- Rules not updated in at least 10 years
- No state EMS transportation plan
- No stroke/STEMI designation
- No linkage between EMS and trauma registries or crash data
- Trauma System Plan (2004): NOT updated
- Epidemiologist position vacant
- Inter-facility critical care transfer deficiencies NOT addressed
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall characterization:It is clear that in the 10 years since the last assessment, Michigan has made tremendous strides in building its EMS and trauma system and the assessment team applauds your work." (Introduction, p.8)
A culture that welcomes input and critique is hard to develop... This doesn't seem to be an issue for Michigan." (Introduction, p.8)
The overall tone is notably positive — among the most affirmative in the corpus. The TAT uses language like "tremendous strides," "applauds," "commendable," "best practice," and "incredible state partner."
Structural barriers identified:- Crime Victims Services Fund sunset — potential loss of $3,500,000 (over half of Division budget)
- 61 MCAs with variable accountability and performance
- Rules not updated in at least 10 years
- No state designation for stroke, STEMI, burns, or pediatric facilities
- Rural access challenges: 19% population, 75% land mass
- Volunteer sustainability questioned
- No EMD regulation by BETP (falls under Michigan Public Service Commission)
- No linkage between registries or to crash data
- Unregulated proliferation of high-level trauma centers in urban areas
The report frames EMS and trauma firmly within the healthcare continuum. 2006 IOM Report and 2016 NASEM report both referenced in Background. Trauma system developed as model for stroke/STEMI systems of care. EMS integrated with injury prevention, public health, and preparedness.
Federal funding mechanisms:- Highway safety funds: original TAT mechanism; OHSP supported assessment and previously funded MI-EMSIS and trauma registry
- HRSA grant: AED placement program
- FLEX grant: EMS Leadership Academy
- PHEP and HPP: preparedness programs
- EMS-C Partnership Grants: MI-MEDIC cards, pediatric initiatives
- 2016 NASEM report referenced
- Trauma system development since 2007 — "budding inclusive" system
- 8-region infrastructure as "particular strength"
- MCA system as consistent coordination mechanism
- BETP staffing growth
- Preparedness: "particularly strong capability"
- DOSE program: record low infant sleep-related deaths
- Burn Surge Plan development
- Region 6 patient tracking best practice
- EMS Leadership Academy for rural agencies
- Culture of transparency and self-evaluation
- Strong injury prevention partnerships
- Crime Victims Services Fund sunset ($3,500,000 at risk)
- EMD not licensed or certified
- Rules outdated (10+ years)
- MCA variability in performance
- Volunteer workforce sustainability
- No stroke/STEMI state designation
- No EMS-trauma registry linkage
- Unregulated proliferation of urban high-level trauma centers
- State Medical Director at 0.32 FTE for 10 million population
- Inter-facility critical care transfer quality gaps
- Epidemiologist position vacant
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
Most Positive Tone in Corpus
The Michigan 2017 report is among the most affirmative in the corpus. The TAT described "tremendous strides" and "applauds your work." Preparedness was called "a particularly strong capability." The culture was praised for embracing transparency. This contrasts sharply with assessments of contemporaneous states where stagnation or regression was the dominant finding.
Crime Victims Services Fund — Unusual and Precarious Funding
The Division of EMS and Trauma's primary funding source ($3,500,000 of $6,565,600) is the Crime Victims Services Fund — an unusual and apparently unique funding mechanism in the corpus. The TAT described its potential sunset in 2018 as "devastating," placing over half the Division budget at risk.
DOSE Safe Sleep Program — Public Health Innovation
The Direct on Scene Education (DOSE) program — training EMS providers to identify unsafe infant sleep practices during emergency responses, with 500+ Pack N Plays distributed — contributed to moving from a record high of infant sleep-related deaths in 2015 to a record low in 2016. Michigan is one of 6 states in the program. This is a novel EMS-public health intersection.
Unregulated Proliferation of High-Level Trauma Centers
The TAT identified a unique concern: the concentration of 8 Level I and 23 Level II trauma centers in urban areas risks "diluting specialty resources" and causing "competition amongst hospitals for the same patient cohort." The TAT recommended regulation based on the ACS Needs Based Assessment tool — an unusual recommendation to limit rather than expand trauma system access.
0.32 FTE State Medical Director for 10 Million Population
The State EMS Medical Director serves at 0.32 FTE for a state of nearly 10 million — the lowest FTE ratio for a state of this population in the corpus. The TAT explicitly noted that "the majority of states support a 0.5 FTE for their State EMS Medical Directors, most of which have smaller populations than Michigan."
50% Volunteer/Paid-on-Call Workforce
Up to 50% of Michigan's EMS workforce is less than full-time compensated. Combined with the TAT's statement that "it is unlikely that volunteer models for EMS delivery are sustainable in the long term," this represents a significant structural vulnerability.
Human Trafficking Training Integration
Michigan was described as the "number two state in the country for human trafficking," with discussion of integrating recognition/reporting training into initial EMS education curricula. This is a novel EMS education content area not documented in other assessed states.
4-Year Funding Delay for Trauma System
Trauma Administrative Rules were approved by the legislature in 2008, but funding was not appropriated until 2012 — a 4-year gap between authorization and appropriation that delayed the entire trauma system implementation.
13th Year High School Paramedic Pathway
Discussion of utilizing Michigan's unique high school "13th year" option — allowing graduating seniors an additional year to obtain paramedic certification — is a novel workforce pipeline concept not documented elsewhere in the corpus.
356 Rural AEDs: 6 Uses, 5 Saves
The HRSA-funded rural AED placement program documented 6 uses and 5 saves — an 83% save rate — providing rare outcome data for a public access defibrillation program.
Analysis produced using standardized NHTSA State EMS Assessment extraction framework. All quotes are from the Michigan 2017 Reassessment report. No editorial synthesis applied.
Mississippi
Full Analysis
Mississippi 2004 NHTSA State EMS Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of Mississippi
- Report type: Reassessment
- Date of site visit: April 20–22, 2004
- Year of publication: 2004
- Prior assessment year: 1991
- TAT members:
- Theodore R. Delbridge, MD, MPH, FACEP — Associate Professor of Emergency Medicine & Health Policy and Management, University of Pittsburgh; Principal Investigator, EMS Agenda for the Future; Board of Directors, NAEMSP
- Leonard R. Inch — Regional Executive Director, Sierra-Sacramento Valley EMS Agency, California; Past President, EMSAAC
- Christoph R. Kaufmann, MD, MPH, FACS — Associate Medical Director, Trauma Services, Legacy Emanuel Hospital, Portland; Professor of Surgery, USUHS; Former Director, HRSA Division of Trauma and EMS; HRSA Model Trauma Care System Plan Ad Hoc Committee (1992, 2003)
- W. Dan Manz — Director, EMS Division, Vermont Department of Health; Past President, NASEMSD; Co-Chair, EMS Agenda for the Future; PI, National Scope of Practice Model Project
- Susan D. McHenry — EMS Specialist, NHTSA (NHTSA facilitator); Past President, NASEMSD
- NHTSA facilitator: Susan D. McHenry
- Number of presenters/briefings: Over 30 presenters
- Requesting agency: Mississippi Bureau of Emergency Medical Services (BEMS), in concert with the Mississippi Governor's Highway Safety Office
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not explicitly stated.
- Geographic characteristics: Not described in geographic detail (no square miles, no rural/urban breakdown). The report references 7 trauma care regions: Delta, North, Central, East Central, Southwest, Southeast, and Coastal. Rural areas with single ambulances and long-distance transfers are referenced (p. 14).
- Number of counties/jurisdictions: Not explicitly stated but implied: the report references multi-county medical direction areas and paramedic coverage gaps in 5 counties (p. 14). Mississippi has 82 counties.
- EMS system overview:
- BEMS Director: Keith Parker
- State EMS Medical Director: None at the time of assessment — "there is currently not a state EMS medical director, though there are plans to appoint one" (p. 23)
- Advisory structure: Emergency Medical Service Advisory Council (EMSAC); Mississippi Trauma Advisory Committee (MTAC); Medical Direction, Training and Quality Assurance Committee (MDTQA)
- Number of agencies/providers: 137 ambulance services; 660 licensed ambulances; 7 helicopter providers (3 Mississippi-based); paramedic coverage reaching 98% of the population; 16 community colleges offering EMT-B (at 23 campuses); 7 community colleges offering paramedic training
- Hospitals: 113 hospitals in the state; 92 with EDs; 67 JCAHO accredited, 46 not
- Trauma system: 7 trauma care regions; 2 Level I (including 1 in Memphis, TN), 5 Level II, 8 Level III, 51 Level IV; voluntary hospital participation
- Notable demographic or socioeconomic factors cited:
Sixty-four percent of families with children are low income or poor (national average 46%). Mississippi has the lowest proportion of high school graduates of any state in the nation." (p. 5)
The state is consistently among the top three states in the nation for death rates from motor vehicle crashes. Similarly Mississippi has very high rates of smoking, heart disease deaths and physical inactivity." (p. 5)
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:The Mississippi Department of Health has a vision for EMS that is clearly stated and unambiguous." (p. 5)
The Mississippi Trauma Care System Plan has been written, implemented, and serves to match an appropriate response to the needs of patients." (p. 16)(b) Specific data points: A Trauma Care System Plan exists and is implemented. EMS and trauma regulations have been created and are updated. No separate comprehensive statewide EMS plan (distinct from trauma) is identified in the document. (c) TAT characterization: The TAT commends the vision and implementation of the trauma care system plan but does not identify a comprehensive statewide EMS plan covering all system components. The focus is heavily on the trauma system as the organizing framework. (d) Priority recommendation: Not documented in this report as a bold/priority recommendation for a comprehensive EMS plan.
3B. Funding and Financial Sustainability
(a) Direct quotes:Mississippi's funding mechanism of capturing a portion of moving motor vehicle violation fines has been a model for many other states." (p. 5)
A permanent source of revenue for the trauma care system was established at the same time through a $5 assessment on moving traffic violations, creating the Trauma Care Trust Fund." (p. 26)
In 1999, the legislature added $6 million to the Trauma Care Trust Fund from the state tobacco settlement resulting in a total available funding of approximately $8 million per year." (p. 26)
he system is not fully funded and this under funding is creating pressure on the hospitals and physicians who are providing essential services." (p. 7)
The funds were first distributed in 2000 and divided with 70% to trauma hospitals and 30% to eligible physicians." (p. 27)
at some point the hospitals and care providers will need to be adequately compensated." (p. 27)(b) Specific data points:
- $5 assessment on moving traffic violations — Trauma Care Trust Fund (permanent)
- $6 million added from tobacco settlement (1999)
- Total trauma system funding: approximately $8 million/year
- Distribution: 70% to trauma hospitals, 30% to eligible physicians
- System described as not fully funded
- FLEX funding used for paramedic scholarship program
- Federal grant funding from DOJ, HRSA, and CDC for disaster preparedness
- 56 contracted ambulances for disaster response
- 17 WMD Centers of Excellence and 11 Supportive Centers funded
- No dedicated EMS operations funding source (distinct from trauma) documented
Continue efforts to achieve full funding for uncompensated and under-compensated trauma care. Fund the system adequately so support to out-of-state trauma centers does not negatively impact compensation to in-state centers and providers." (p. 8)
The Mississippi Legislature should fully fund the administration and uncompensated care costs of the trauma care system." (p. 27)
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:ver an eight-year period, the number of paramedics within the system climbed by 43% while call volume rose only 23%." (p. 12)
he state currently has an adequate number of paramedics in the system. While the total number of paramedics in the system may be sufficient, the study did not rule out local shortages which are suggestive of workforce distribution problems." (p. 12)
Paramedics do not provide coverage in five counties." (p. 14)
First time pass rates for EMT-Basics and Paramedics on National Registry of EMTs testing have risen in the past year from 60+% rates to 80+% rates." (p. 12)(b) Specific data points:
- Paramedic workforce: 43% growth over 8 years vs. 23% call volume growth
- 98% population covered by paramedic ambulance service
- 5 counties without paramedic coverage
- All EMTs and paramedics nationally registered
- 16 community colleges / 23 campuses for EMT-B training; 7 colleges for paramedic
- All but 1 paramedic program at associate degree level (post-curriculum revision)
- One-time paramedic certification drop in 2002 due to degree transition
- First-time NREMT pass rates: improved from 60+% to 80+%
- Declining EMT-Intermediates (training discontinued by policy)
- First responders: not certified by BEMS; widely used by fire departments
- No state instructor certification/preparation program
- Paramedic scholarship fund via FLEX resources
- CISM program in development
BEMS should continue with the implementation of the Statewide Performance Improvement Plan [for] Prehospital Care.
BEMS should begin licensing non-transporting EMS agencies (e.g. fire departments) as a mechanism to facilitate the certification of personnel in other than traditional ambulance service settings.
3D. Essential Service Designation
Not documented in this report. The phrase "essential service" appears once in the context of underfunding "creating pressure on the hospitals and physicians who are providing essential services" (p. 7) — used descriptively, not as a legal/policy designation.3E. Regulatory Fragmentation
(a) Direct quotes:A notable gap in the Mississippi EMS legislation is the lack of ability to license and regulate non-transporting EMS organizations." (p. 8)
nationally registered EMTs and paramedics working in non-transporting fire departments are only able to function with a first responder scope of practice at the scene of a medical call." (p. 8)
There are EMS personnel in the state unaffiliated with ambulance services. The system infrastructure to allow efficient access and effective utilization of this essential resource is not in place." (p. 9)(b) Specific data points:
- BEMS cannot license or regulate non-transporting EMS agencies
- EMTs/paramedics in fire departments limited to first responder scope
- Regional EMS medical direction exists in only 3 areas; others lack coordination
- 2 of 7 trauma care regions use non-standard triage protocols
- Multiple independent dispatch centers requiring hand-offs
- All but 4 counties have 911 access; not all are E-911
- Hospital participation in trauma system is voluntary
- Not all hospitals participate; some below their capability level
BEMS should seek a change in statute to allow for authority to license and regulate non-transporting EMS agencies and personnel.
3F. Data and Evaluation Systems
(a) Direct quotes:The state has one of the most mature and well developed information systems of any EMS system in the nation." (p. 5)
Development, implementation, maintenance, and ongoing improvement of MEMSIS are extraordinary accomplishments, and MEMSIS is a model for other state EMS systems." (p. 29)
This comprehensive system currently holds nearly 3,800,000 records. The data from every patient care record in the state has been electronically submitted to MEMSIS since 1999." (p. 29)
Two important current limitations of the system are its lack of linkage to the crash data system and to hospital emergency department registries or discharge information." (p. 29)
A familiar limitation of the EMS system is its inability to describe patients' experiences throughout the entire illness or injury event." (p. 29)
he current registry is cumbersome to query, greatly limiting its utility for evaluation efforts." (p. 29)(b) Specific data points:
- MEMSIS (Mississippi EMS Information System): operational since 1999; nearly 3,800,000 records
- Electronic submission of every patient care record statewide since 1999
- Integrated reports for local EMS agencies; periodic BEMS reports; custom query capability
- No linkage to crash data or hospital ED/discharge data
- No CODES project
- Trauma registry: data from designated trauma hospitals only; "cumbersome to query"
- No submission to National Trauma Data Bank (NTDB)
- Local QI officers required; no statewide guidance for local QI activities
- Statewide Performance Improvement Plan for Prehospital Care: developed but "in a fledgling stage" (p. 29)
- QI confidentiality: not specifically addressed
The Mississippi Legislature should provide the necessary statutory and/or regulatory changes to generate reliable feedback from EMS-receiving hospitals, to EMS agencies, with specific patient outcome data.
BEMS should expedite implementation of sustained evaluation efforts in focused areas of structure, processes and outcomes.
BEMS should expedite implementation of the Statewide Performance Improvement Plan [for] Prehospital Care.
3G. Trauma System Status
(a) Direct quotes:There is a rich history of progress in improving and organizing the system of care available to sick and injured citizens." (p. 5)
he trauma system infrastructure is 'in very good shape'" (p. 27)
The overall incidence of trauma and trauma mortality rates for specific injuries in Mississippi are unknown and must be identified in order to determine the effectiveness of the trauma care system." (p. 27)(b) Specific data points:
- 7 trauma care regions with regional boards
- 2 Level I (1 in Memphis, TN), 5 Level II, 8 Level III, 51 Level IV
- Hospital participation: voluntary; some hospitals not participating or participating below capability
- 92 hospitals with EDs; not all participate
- 3-year re-inspection cycle for trauma center designation
- $8 million/year trauma funding (traffic violations + tobacco settlement)
- 70% to hospitals / 30% to physicians
- Trauma Care Task Force: 17 members, established 1997
- Trauma legislation: authorizing BEMS to develop statewide system
- Trauma registry: operational, designated hospitals only; not NTDB-submitting
- Triage protocols: 5 of 7 regions use state model; 2 use own protocols
- University Hospital diversion: reduced from "more often than open" (early 1990s) to "only a few hours per month"
- Not all neurosurgical subspecialty groups participate
- Coroner system: deaths not investigated by medically qualified personnel; Medical Examiner position vacant; autopsies performed by non-forensic pathologists; information "of no value from a system improvement perspective" (p. 8)
The Mississippi Legislature should fully fund the administration and uncompensated care costs of the trauma care system.
The Department of Health should identify additional funding to encourage subspecialty physician participation in the care of injured patients. The current lack of neurosurgery participation in some hospitals and complete lack of neurosurgery capability in other hospitals severely limits the overall capability and effectiveness of the Mississippi trauma care system. Recruiting neurosurgeons needs to be a trauma system priority.
The Mississippi Legislature should support medical tort reform in order to protect the existing healthcare provider workforce and attract more participant physicians.
3H. Medical Direction
(a) Direct quotes:At the state level, there is currently not a state EMS medical director, though there are plans to appoint one." (p. 23)
Regional district EMS medical direction exists in three areas of the state. In the others, there is little or no coordination among EMS medical directors within their respective regions." (p. 23)
it is quite possible for EMS medical directors of individual agencies to function in relative isolation from the rest of the state's EMS system." (p. 24)
There is currently not a uniform process of credentialing or educating EMS medical directors." (p. 24)
There is currently no system-wide liability protection for medical directors." (p. 7)
Most physicians serve in medical director roles without compensation." (p. 7)
concern about changing the nature of the relationship with EMS agencies, and the potential for liability, is a factor in not seeking appropriate compensation for bona fide services provided." (p. 24)(b) Specific data points:
- No State EMS Medical Director (plans to appoint one)
- Regional EMS medical direction: only 3 of 7 regions
- Remaining regions: "little or no coordination"
- Medical directors: no credentialing, no education requirements, no specialty qualifications
- Most serve without compensation
- No liability protection
- Medical direction not mandated for first responder activities
- Medical direction required for all EMS transport agencies including EMT-B
BEMS should appoint a state EMS medical director who has overall responsibility and authority to oversee the state's EMS medical direction processes.
BEMS should establish regional EMS medical directors throughout the state.
BEMS should seek and implement solutions that protect physicians from potential liability incurred during fulfillment of their duties as EMS medical directors.
3I. Communications and Infrastructure
(a) Direct quotes:Traditional EMS radio networks have fallen into decline. Cellular and other forms of communications have become more prevalent." (p. 20)
many agencies still maintain independent dispatch centers requiring the hand off and multi-agency involvement in the dispatch of an incident." (p. 19)(b) Specific data points:
- All but 4 counties have 3-digit 911 access to PSAPs
- APCO dispatcher certification required for all dispatchers
- Emergency Telecommunications Training Program: legislatively established with Board of Standards
- Satellite communications being explored; pilot program near implementation in Delta Region
- All hospitals funded to purchase satellite communications
- Traditional EMS radio networks declining
- Health Alert Network: call-down system, blast fax, satellite radio, videoconferencing
- No statewide EMS radio system
- Communication plan not filed with FCC
- Independent dispatch centers with multi-agency handoffs persist
BEMS should continue to pursue the promising benefits of satellite technology. Because of the unproven capacity of the technology, BEMS should proceed carefully.
BEMS should reconsider the support of traditional EMS radio communications and incorporate those networks into the EMS communications infrastructure as appropriate.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (1991 Assessment)
The report integrates progress reporting within each section rather than providing a systematic accounting. Key progress since 1991:
Completed or Substantially Accomplished:
- Trauma care legislation enacted with permanent funding mechanism
- Trauma Care Trust Fund established ($5/ticket + tobacco settlement = ~$8M/year)
- Statewide trauma care system implemented with 7 regions and designation process
- MEMSIS developed and operational since 1999 (~3.8M records)
- Medical direction mandated for all EMS transport agencies
- MDTQA committee established
- Statewide dispatcher training program implemented
- Paramedic coverage expanded to 98% of population
- Secondary safety belt law passed
- Field triage protocols developed and implemented (5 of 7 regions)
- Closest-ambulance dispatch across county lines
- CISM program developed
- WMD Centers of Excellence (17) and Supportive Centers (11) designated
- Hospital Status System (web-based) developed
- BEMS communications assessment conducted
Not Completed or Partially Accomplished:
- No State EMS Medical Director (plans only)
- Non-transporting agency licensing authority: not obtained
- First responder certification: not implemented
- Primary safety belt law: not enacted (secondary law only)
- Medical examiner position: vacant
- Full trauma system funding: not achieved
- EMS communications plan: not filed with FCC
- Statewide response time guidelines: not completed
- All-hospital trauma system participation: not achieved
- Data linkage to crash data and hospital outcomes: not achieved
- NTDB submission: not occurring
- Statewide PI plan: developed but implementation nascent
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization of the EMS system:The TAT frames Mississippi's EMS system as a story of accomplishment against adversity:
Emergency medical services (EMS) and trauma care for the citizens of Mississippi stands in contrast to the existing health status of the state's population as a whole." (p. 5)
The many accomplishments have been achieved in an environment of some of the poorest public health indicators in the country." (p. 5)
The staff of the EMS and trauma program are motivated, goal driven and their work is performance-based." (p. 5)
Innovative thinking, relevant partnerships, applied technology and a 'can do' attitude have created a substantial safety net for the people of Mississippi." (p. 5)Structural barriers identified:
- Inability to license/regulate non-transporting EMS agencies (statutory gap)
- No state EMS medical director
- Incomplete regional medical direction structure (3 of 7 regions)
- No medical director liability protection
- Uncompensated medical director service
- Voluntary hospital trauma participation
- Neurosurgical subspecialty gaps
- Dysfunctional coroner/medical examiner system
- Tort law environment deterring physician participation
- No primary safety belt law
- Poverty and educational attainment as underlying determinants
The Background reflects the standard NHTSA transportation framework. However, the body operates within a hybrid — the $5/moving violation funding mechanism directly ties EMS/trauma to traffic safety, while the system's design (disease-based trauma regions, hospital designation, clinical performance improvement) reflects a healthcare framework. The Introduction explicitly positions EMS against the state's broader public health context, and the Emergency Planning component (added at the state's request) adds a preparedness dimension.
Federal funding mechanisms referenced:- Highway safety funds — assessment mechanism
- FLEX funding — paramedic scholarship program
- DOJ, HRSA, CDC grants — disaster preparedness
- Tobacco settlement — $6M added to Trauma Care Trust Fund
- Federal bioterrorism preparedness funding — referenced as needing to be "leveraged to support system infrastructure" (p. 5)
- MEMSIS — "one of the most mature and well developed information systems of any EMS system in the nation"
- Trauma Care Trust Fund — $5/ticket mechanism as "model for many other states"
- Trauma care system with 7 regions and 66 designated hospitals
- 98% paramedic population coverage
- BEMS staff: "motivated, goal driven... performance-based"
- Formal workforce analysis demonstrating adequacy
- WMD Centers of Excellence (17) with surge capacity
- University Hospital diversion reduction (near-constant → a few hours/month)
- Associate degree paramedic education at all but 1 program
- NREMT pass rate improvement (60+% → 80+%)
- Incomplete trauma system funding ("creating pressure")
- Non-transporting EMS agency licensing gap (fire department paramedics limited to first responder scope)
- No state EMS medical director
- Fragmented regional medical direction
- No medical director liability protection or compensation
- Neurosurgery subspecialty shortages
- Dysfunctional coroner/medical examiner system
- Poorest public health indicators in the country as underlying context
- No primary safety belt law (top-3 national MVC death rate)
- Medical tort reform needed to sustain specialty physician workforce
- Unproven satellite communications technology
- Data system lacking outcome linkage
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. "Stands in contrast." The TAT's framing of Mississippi's EMS achievements against "some of the poorest public health indicators in the country" (p. 5) is the most explicit acknowledgment in this corpus of the socioeconomic context in which an EMS system operates. The 64% child poverty rate and lowest national high school graduation rate are cited as the environment within which a nationally recognized data system and innovative trauma funding have been built.
2. MEMSIS as national data model. With nearly 3.8 million records and complete electronic submission since 1999, MEMSIS represents the most advanced prehospital data system documented in any NHTSA assessment in this corpus. The contrast with South Dakota (2002, new system just installed), California (1999, 1 QI employee), Colorado (1997, data collection "abandoned"), Massachusetts (1992, no uniform run form), and even Maryland (2004, still paper-based) is stark. Mississippi achieved universal electronic data collection five years before Maryland was piloting its system.
3. $5/ticket funding mechanism. The Trauma Care Trust Fund via traffic violation assessments, described as "a model for many other states," represents a creative dedicated funding source directly tying highway safety behavior to trauma system support. The tobacco settlement addition ($6M) demonstrates legislative willingness to augment the fund.
4. Non-transporting agency gap as structural exclusion. The inability to license non-transporting agencies creates a paradox: nationally registered paramedics working in fire departments can only function as first responders on medical calls. This is documented as the primary regulatory gap and appears in recommendations in at least four separate sections (Regulation, Resource Management, Human Resources, Transportation).
5. Formal workforce adequacy finding. Mississippi is the only state in this corpus where BEMS conducted a formal workforce analysis that found adequate total paramedic numbers (43% growth vs. 23% call volume growth). This quantitative approach stands in contrast to "perceived shortages" documented elsewhere. The identification of distribution rather than total supply as the problem is analytically significant.
6. Medical tort reform as EMS system recommendation. The TAT recommends that "The Mississippi Legislature should support medical tort reform in order to protect the existing healthcare provider workforce and attract more participant physicians" (p. 27). This recommendation extends beyond the EMS system into the broader healthcare legal environment — an unusually broad policy recommendation for a NHTSA assessment.
7. Coroner/medical examiner system as trauma system failure. The TAT documents that trauma deaths are "not being investigated by medically qualified personnel," the Medical Examiner position is vacant, autopsies are performed by non-forensic pathologists, and the information gathered is "of no value from a system improvement perspective" (p. 8). This represents a complete dysfunction of the death investigation component of the trauma system.
8. Out-of-state Level I trauma center. Mississippi's trauma system includes a Level I center in Memphis, Tennessee (p. 17) — a cross-border accommodation also seen in Connecticut (2000, Massachusetts hospital). The TAT specifically recommends that full funding not "negatively impact compensation to in-state centers" due to out-of-state support (p. 8).
9. University Hospital diversion transformation. The reduction from near-constant diversion in the early 1990s to "only a few hours per month" by 2004 (p. 17) documents a measurable system improvement attributable to the trauma system's triage and transport protocols.
10. Satellite communications as frontier technology. Mississippi's exploration of satellite communications for EMS represents a technologically distinctive approach — moving beyond traditional radio and digital microwave to non-terrestrial solutions. The TAT's cautious endorsement ("proceed carefully") reflects the unproven nature of the technology.
11. Emergency Planning as 11th component. Following California (1999, Disaster Systems) and Maryland (2004, Homeland Security), Mississippi adds Emergency Planning. The WMD Centers of Excellence with 500-patient regional surge capacity and stockpiled medications represent a systematic post-9/11 preparedness investment. The weekly communication with the Choctaw Nation regarding emergency planning is a notable tribal engagement finding.
12. Ted Delbridge returns. TAT member Theodore Delbridge — Principal Investigator of the EMS Agenda for the Future (1996) — was previously on the Colorado reassessment TAT (1997). His presence on both the Colorado and Mississippi teams provides intellectual continuity across the assessment program, particularly regarding the Agenda's influence on system evolution.
Analysis extracted: February 2026. Source document: State of Mississippi, A Reassessment of Emergency Medical Services, NHTSA Technical Assistance Team, April 20–22, 2004.
Missouri
Full Analysis
Missouri 2010 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Missouri
- Report type: Reassessment
- Date of site visit: June 22–24, 2010
- Year of publication: 2010
- Prior assessment year: 1994
- TAT members:
- Christoph Kaufmann, MD, MPH, FACS
- Terry Mullins, MBA
- Susan D. McHenry, MS
- Curtis Sandy, MD, FACEP
- Jolene R. Whitney, MPA
- NHTSA facilitator: Susan D. McHenry, MS (listed as TAT member; no separate facilitator distinguished in text)
- Number of presenters/briefings: Over 25 presenters over the first day and a half (Background, p.4)
- Requesting agency: Missouri Department of Health and Senior Services (DHSS)
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not documented in this report (no population figure stated)
- Geographic characteristics: Described as having "a tremendous breadth of population densities" (Facilities); both urban and rural areas; "a large state with both urban and rural areas" (Trauma Systems). Missouri borders 8 states and provides trauma care to patients from surrounding states.
- Number of counties/jurisdictions: 114 counties implied — 91 counties have implemented 911 systems, 6 are in process, 17 provide only a ten-digit number for emergency calls (Communications)
- EMS system overview:
- Implementing statute: Chapter 190 (190.001–190.245) of the Missouri Revised Statutes, collectively titled the "Comprehensive Emergency Medical Services Systems Act"
- 214 ground ambulance services, 15 air ambulance providers, 35 Emergency Medical Response Agencies (EMRAs) (Transportation)
- 6 EMS regions (Resource Management)
- Approximately 17,000 licensed EMTs (Human Resources)
- 25% of services are fire-based; majority provided by ambulance service districts (Transportation)
- Notable demographic or socioeconomic factors cited:
The review team heard many references to Missouri being a 'low tax-low service' state." (Regulation and Policy, p.12)
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:Other glaring issues that impede development of a comprehensive statewide EMS system are the lack of a statewide EMS plan." (Resource Management, p.17)
DHSS should work through SAC-EMS to develop and implement a comprehensive statewide EMS plan." (Resource Management Recommendations)(b) Data points: No statewide EMS plan exists as of the reassessment. (c) TAT characterization: Called the absence a "glaring issue" that "impede[s] development of a comprehensive statewide EMS system." (d) Priority recommendation: Yes — recommended that DHSS develop and implement a comprehensive statewide EMS plan through SAC-EMS, ensuring "an inclusive system of care for the emergency healthcare system (Trauma, STEMI, Stroke and others as appropriate), to include all patients, providers, agencies and hospitals."
3B. Funding and Financial Sustainability
(a) Direct quotes:Funding to support BEMS staff comes from several sources including general revenue, the federal Public Health Block Grant, the Federal Emergency Medical Services for Children grant program, the Heart Disease and Stroke Prevention program and the Missouri Foundation for Health." (Regulation and Policy, p.12)
None of the funding sources identified for staff or program activities is secure." (Regulation and Policy, p.12)
The Missouri Foundation for Health funding for the EMS Medical Director's position will end in 2012 and the imminent passage of the time critical diagnosis system regulations will require additional staffing." (Regulation and Policy, p.12)
Statutory language requires the Department to establish fees for licensure services, but previous efforts to promulgate rules were stopped due to opposition." (Regulation and Policy, p.12)
There is no dedicated funding source to offset the cost of uncompensated trauma care within Missouri." (Facilities, p.26)
It is this lack of sustainable funding that poses the greatest threat to the Missouri trauma system." (Trauma Systems, p.37)
The missing resource is financial support. Each region needs enough funding to develop and implement a regional trauma plan, collect data, and perform quality improvement/system development." (Trauma Systems, p.38)(b) Data points:
- BEMS staff reduced from 25 to 10 over 16 years (1994–2010) (Regulation and Policy, p.12)
- State EMS Medical Director funded by Missouri Foundation for Health — funding ends 2012
- No specific dollar amounts for BEMS budget cited in report
- Licensure fee rules previously blocked by opposition
- Additional funding sought from Office of Rural Health, Center for Emergency Response and Terrorism, Missouri Departments of Transportation and Homeland Security
- DHSS should secure a reliable funding source to maintain BEMS office infrastructure and to offset uncompensated trauma care (Facilities Recommendations)
- The State legislature should provide sustained adequate funding to maintain the BEMS office, the State EMS Medical Director position, and develop and maintain EMS regional advisory committees (Trauma Systems Recommendations)
- The Department should reintroduce rules regarding licensing fees (Regulation and Policy Recommendations)
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:The state has not performed an assessment to determine if there are adequate EMS providers and has received only sporadic reports of shortage of personnel." (Human Resources, p.20)
Currently, Missouri's NREMT pass rates are well below the national average." (Human Resources, p.20)
Over the past 16 years, the Bureau of EMS has gone from a staff of 25 to a staff of 10." (Regulation and Policy, p.12)(b) Data points:
- 17,000 licensed EMTs statewide
- NREMT pass rates "well below the national average"
- BEMS staff: 10 (down from 25)
- All EMTs require NREMT certification for 5-year initial or relicensing period
- Ambulances required to be staffed with 2 EMTs; volunteer services may use a first responder as driver
- 98% (210 of 215) licensed ambulance services have some ALS capability
- 6 BLS-only services
- Beginning 2009, training programs below national first-attempt NREMT pass rate subject to progressive technical assistance
- Perform a workforce analysis to determine the impact of reducing license periods from 5 to 3 years
- Develop technical assistance program for training programs based on best practices from high-pass-rate programs
- Prioritize regulatory changes for 2013 EMT nomenclature/scope/education standards changes
3D. Essential Service Designation
(a) Direct quotes:Lack of centralized coordination of EMS assets at the state level and the practice of determining EMS coverage through local ambulance districts makes it virtually impossible to assure that the citizens of Missouri receive equal access to emergency care." (Resource Management, p.17)
There are obvious needs in some jurisdictions that lead to disparities in the delivery of EMS care and create underserved populations or geographic areas." (Resource Management, p.17)(b) Data points: Not documented in this report — no specific essential service designation language or recommendation. (c) TAT characterization: The report does not use the term "essential service." EMS is described through the framework of ambulance districts and local determination, with resulting disparities noted. (d) Priority recommendation: Not recommended in this report.
3E. Regulatory Fragmentation
(a) Direct quotes:While specific language denoting the Department's and Bureau's role in implementing a comprehensive EMS system is not identified in statute, there is clear evidence of the Department's efforts to accomplish these activities." (Regulation and Policy, p.11)
The net effect is that Missouri appears to have an EMS confederation rather than an EMS System." (Resource Management, p.16)
Missouri is divided into six EMS regions, which are helpful in coordination of response and EMS resource management, but regional committees lack authority or oversight capacity and function only in an advisory role." (Resource Management, p.16)
Statutes notably do not include language that:
Charges the Department with the responsibility to establish and enhance a statewide EMS system" (Regulation and Policy, p.12)
Delegates any regulatory authority for the establishment or enhancement of the EMS system to the regional councils" (Regulation and Policy, p.12)(b) Data points:
- 6 EMS regions — advisory only, no authority
- 96 independent dispatch centers (Communications)
- 91 counties with 911; 6 implementing; 17 with ten-digit emergency numbers only
- No regulations require dispatch centers to provide EMD
- No licensing standards for emergency medical dispatchers
- Pediatric EMS system authorized in statute but no regulations written to implement it
- Pass legislation specifically describing DHSS's role as agency charged with implementing and enhancing the EMS system
- Pass legislation to delegate specific authorities to regional EMS committees
- Introduce enabling legislation to allow regional EMS committees to become not-for-profit corporations
- Establish statutory authority for EMD standards and dispatcher licensing
- Continue collaborative efforts to resolve 911 system fragmentation
3F. Data and Evaluation Systems
(a) Direct quotes:Data reporting to the state EMS Bureau that is less than optimum. The policy of submitting only the 'life threat' reports to the Bureau, based on 1998 guidance for the Missouri Ambulance Reporting Form at the time, is woefully inadequate." (Resource Management, p.17)
EMS agencies are required to submit NEMSIS information on 'life-threat' calls only which make up less than 10% of the call volume. 'Life-threat' is not defined in rule and is up to individual agency interpretation." (Medical Direction, p.35)
A new State minimum data set from all EMS patient care reports in the state must be submitted in a NEMSIS compliant electronic format." (Resource Management, p.17)(b) Data points:
- Only "life-threat" reports submitted — less than 10% of total call volume
- "Life-threat" not defined in rule; left to individual agency interpretation
- NEMSIS-compliant reporting not yet implemented for all calls
- No data linkage to hospital outcomes documented
- DHSS has a CODES project referenced in recommendations
- Missouri Information for Community Assessment (MICA) database exists within DHSS for epidemiology but is "underutilized by hospitals and EMS agencies" (Public Information, p.31)
- DHSS should require ALL EMS patient care reports submitted to BEMS
- BEMS must develop a minimum data set and method to adequately monitor and measure statewide EMS performance
- DHSS should consider linkage of EMS data with CODES project and TCD databases
- Use EMS patient care reports for syndromic surveillance
- Require submission of trauma patient care data to the State Trauma Registry from all licensed acute care facilities
The State does not have a comprehensive EMS system evaluation process in place. The function of system evaluation has been left to the individual agency to develop and monitor without state minimum performance standards." (Evaluation, p.40)
Even with the receipt of limited data, there is no systematic data analysis process in place." (Evaluation, p.41)
There is no full time data manager in the BEMS. While epidemiologists are available, there is no dedicated support for the trauma registry and MARS." (Evaluation, p.41)
The trauma registry collects data from designated trauma centers. This data is available for reference or report generation but is not actively analyzed and not routinely disseminated." (Evaluation, p.41)
There is no seamless mechanism for tracking patients from the prehospital to inpatient environments, nor to track individual patients flow within the system." (Evaluation, p.41)
Additional data points:
- Missouri Ambulance Reporting System (MARS) provided free of charge; approximately 80% of agencies use it, though paper PCRs still in use
- State is "nationally recognized for its electronic vital records information system" (Evaluation, p.41)
- Hospital discharge data and injury database exist separate from trauma registry within DHSS Office of Epidemiology
- No peer-review protection for EMS providers and data — currently pursuing agreement with Center for Patient Safety; the development of this PSO "has potential to complicate the statewide evaluation process due to desire by some providers to only report patient care data to the PSO and not to the Bureau" (Evaluation, p.40)
Additional Evaluation recommendations:
- Legislature should establish peer-review protection for EMS providers and data
- Require all ambulances/EMRAs to electronically submit NEMSIS-compliant data on ALL patient encounters into MARS
- Require written patient care report provided to receiving hospital upon patient transfer
- Evaluate air medical utilization for outcomes and appropriateness
- Establish individual patient identification and tracking through TCD system and state databases
- Create a full-time data management position in BEMS for Trauma Registry and MARS
- Request consultation visit from the NEMSIS Technical Assistance Center
3G. Trauma System Status
(a) Direct quotes:The Missouri trauma system was established and continues to exist due to the hard work of medical professionals and the BEMS staff." (Trauma Systems, p.37)
However, there is little funding to support this critical healthcare delivery infrastructure — much of the ongoing work to maintain the system is performed on a volunteer basis." (Trauma Systems, p.37)
It is this lack of sustainable funding that poses the greatest threat to the Missouri trauma system." (Trauma Systems, p.37)
Only 48% of the land area of Missouri is within 60 minutes of a Level I or Level II trauma center by ground or air transport. Eighty-four percent of the population, however, is within 60 minutes of a Level I or II trauma center." (Trauma Systems, p.38; citing TIEP 2009 maps)
The goal of an inclusive trauma system for Missouri is achievable." (Trauma Systems, p.38)(b) Data points:
- 28 designated trauma centers: 10 Level I (including 3 pediatric Level I), 11 Level II, 7 Level III
- Previously 8 Level III — one dropped designation due to call coverage issues
- 3 adult Level I centers verified by the American College of Surgeons
- 8 burn centers providing care — none designated by the State
- 6 EMS regions; all have Level I or II except the Southeast region (Level III only, prevented from Level II by neurosurgery backup call issues)
- Southeast region has highest concentration of counties with highest injury death rates (2000–2006 CDC WISQARS data)
- Verification cycle: 5 years (TAT recommends moving to 3)
- 48% of land area within 60 minutes of Level I/II by ground or air
- 84% of population within 60 minutes of Level I/II
- Voluntary designation process
- No dedicated funding source for uncompensated trauma care
- No state-to-state repatriation agreements (though IL and AR provide some compensation)
- Level IV trauma center standards under development
- Immediately hire a full-time State Trauma System Manager
- Complete a statewide inclusive trauma system plan
- Promulgate statewide trauma field triage and transfer standards
- Legislature should provide sustained adequate funding
- Work toward all citizens within 60 minutes of Level I/II
- Conduct HRSA BIS self-assessment
- Complete Level IV trauma center criteria
3H. Medical Direction
(a) Direct quotes:Missouri has a State EMS Medical Director within the Office of the Director of Health and Senior Services. This position is not established in statute and is funded by the Missouri Foundation for Health." (Medical Direction, p.34)
There is no authority for development of treatment protocols or a statewide quality improvement program." (Medical Direction, p.34)
With no standardized scope of practice or treatment protocols for ALS agencies, on-line medical direction has potential to be problematic due to this variability." (Medical Direction, p.35)(b) Data points:
- State EMS Medical Director position: EXISTS but not in statute, funded by Missouri Foundation for Health (ending 2012)
- 6 Regional Medical Directors established in statute — advisory capacity only
- All ambulance services and EMRAs required to have a physician medical director
- Medical director required: board certification in emergency medicine OR active practice in EM with primary care/surgery board certification, plus ACLS, ATLS, PALS
- No requirement for EMS-specific training for medical directors
- No state certification for EMS medical directors
- No standardized scope of practice or treatment protocols for ALS agencies
- No specific training criteria for physicians providing on-line medical direction
- QI delegated entirely to individual agency level
- Establish the State EMS Medical Director position with appropriate funding (in statute)
- Pursue legislation for State EMS Medical Director authority over QI, protocols, and licensure issues
- Develop comprehensive medical director training and certification
- Establish statutory liability protection for medical directors
- Establish statewide QI standards for low-volume/high-risk procedures (RSI, surgical cricothyroidotomy, thrombolytic administration)
- Require pediatric-specific on-line and off-line medical direction
- Expand Regional Medical Director role to include authority for regional QA oversight
3I. Communications and Infrastructure
(a) Direct quotes:There is a universal 911 number in Missouri; however, implementation of the 911 system is fragmented." (Communications, p.29)
The emergency medical dispatch system has 96 independent dispatch centers located throughout Missouri. No regulations require these 911 centers to provide emergency medical dispatch (EMD). This results in disparities in the timeliness and quality of EMS care." (Communications, p.29)
It was reported that EMS does not have one statewide frequency for all ambulance providers and hospitals to facilitate communications and coordination of patient transports." (Communications, p.29)
Coordinated response may at times be further hindered by a patchwork system of 911, where local dispatch and monitoring capabilities vary from state of the art in some jurisdictions, to non-existent in others." (Resource Management, p.16)(b) Data points:
- 96 independent dispatch centers
- 91 counties with 911 systems implemented
- 6 counties in process of implementing
- 17 counties with only ten-digit emergency number
- No regulations requiring 911 centers to provide EMD
- No licensing standards for emergency medical dispatchers in rule
- No statewide frequency for ambulance-to-hospital communications
- Missouri Highway Patrol has established an interoperable communications plan (law enforcement, fire, EMS, local health departments)
- DHSS can access interoperable system through CPU interface
- EMSystem implemented for hospital bed status/diversion reporting
- Health Alert Network used for event notification
- E-Team used for incident management
- Phase 2 E-911 not consistently available
- Establish statutory authority for EMD and minimum standards for all medical dispatch centers
- Establish state emergency medical dispatcher licensing standards
- Collect fees for personnel licensure and compliance inspections for dispatch centers
- Continue collaborative efforts with DPS to resolve 911 fragmentation
- Conduct assessment of state EMS communications system
- Require 911 centers to monitor EMSystem
- Pursue legislation and funding for Phase 2 E-911
3J. Preparedness
(a) Direct quotes:DHSS and BEMS are actively engaged in emergency preparedness planning and response." (Preparedness, p.43)
Written protocols, approved by medical direction, for EMS assessment, triage, transport and tracking of patients during a disaster are developed at the local level. There is a noticeable lack of protocols at the state level, leaving local agencies to their own devices and creating potential coordination issues during major events." (Preparedness, p.44)
The Missouri Ambulance Reporting System (MARS) cannot be used as a surveillance tool because it only captures a small fraction of the actual number of patient encounters." (Preparedness, p.44)
Highway patrol and disaster response regions do not match EMS regions. This may complicate organized medical response as well as create obstacles to joint grant funding applications." (Preparedness, p.44)
Variable dispatch capabilities throughout the state impede EMS preparedness efforts." (Preparedness, p.44)
Overall, Missouri EMS has demonstrated its ability to prepare for disaster and respond in a timely manner." (Preparedness, p.44)(b) Data points:
- 5 BEMS members assigned to State Emergency Operations Center (SEOC) as liaisons
- 17 supply trailers and several communications trailers provided by DHSS for disaster use
- PPE available for EMS provider use
- BEMS is lead state agency for EMAC requests, FEMA emergency response contracts
- Missouri has adopted NHTSA pandemic influenza model
- Recent deployments: power outages in St. Louis, ice storms and floods in Southeast Missouri, Hurricanes Katrina, Ike, and Gustav
- Patient tracking software exists in many jurisdictions; unclear if capable of uploading to hospital or DHSS databases
- Missouri EMS benefits from "all of the major federal preparedness grants"
- Highway patrol/disaster response regions do not match EMS regions
- Statewide EMS mutual aid plan under development (based on state fire mutual aid plan)
- Require all EMS patient care reports submitted on a real-time basis for syndromic surveillance
- Develop methodology to upload patient care data from tracking systems into state trauma registry and statewide EMS database
- Collaborate with DPS to strengthen EMS communications interoperability
- Improve and standardize EMS dispatch capabilities statewide
- Collaborate with EMS regions to enhance federal grant funding opportunities
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
This is a reassessment of the 1994 assessment (16-year interval).
The report does not include a systematic section-by-section accounting of progress on prior recommendations. The structure follows the 2009 reassessment standards rather than tracking individual 1994 recommendations.
General progress references:Over 25 presenters from the State of Missouri, provided in-depth briefings on EMS and trauma care, and reviewed the progress since the 1994 Assessment." (Background, p.4)
The TAT revisited the ten essential components of an optimal EMS system that were used in the Missouri: An Assessment of Emergency Medical Services, in 1994." (Introduction, p.9)Specific progress documented:
- 1998 Comprehensive EMS Act passed (post-1994 assessment)
- Ambulance district/service licensing system established
- TCD system legislation passed — described as "first in the nation"
- Air ambulance regulations developed
- Six EMS regions established
- State EMS Medical Director position created (though not in statute)
- CoAEMSP accreditation technical assistance provided
- No statewide EMS plan (not present in 1994 or 2010)
- No dedicated sustainable funding source
- No statewide data system beyond "life threat" reports
- No pediatric EMS regulations despite statutory authorization
- Statute still does not charge DHSS with establishing a statewide EMS system
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall characterization:Missouri's EMS system is a reflection of the diverse and complex state it serves. The system has numerous strengths to its credit. Chief among them is the strong commitment of its leadership, agencies and providers, and their willingness to move forward in search of an even greater future." (Introduction, p.8)
Like every other EMS system, there are still opportunities for improvement. The EMS system in Missouri is focused primarily on the local perspective. This focus has served the system well over the years, but now the system is at a crossroads." (Introduction, p.8)
The net effect is that Missouri appears to have an EMS confederation rather than an EMS System." (Resource Management, p.16)Structural barriers identified:
- Statute does not charge DHSS with establishing/enhancing a statewide EMS system
- Statute does not delegate regulatory authority to regional councils
- Statute does not protect EMS data from discoverability
- No pediatric EMS regulations despite statutory authorization
- Local ambulance district model prevents centralized coordination
- Opposition has blocked licensure fee rules
The report explicitly references the healthcare framework:
Emergency Medical Services must be integrated more fully into the overall healthcare system of Missouri and EMS must be recognized at all points in the continuum of care as a true health profession." (Introduction, p.9)
The 2006 IOM Report on the Future of Emergency Care is cited in the Background section as the basis for updated standards reflecting "evolution into a comprehensive and integrated health management system, with regional accountable systems of care."
Federal funding mechanisms:- Highway safety funds referenced in Background as the original funding mechanism for the TAT program
- Public Health Block Grant cited as a funding source for BEMS
- EMS for Children federal grant cited
- ASPR Hospital Preparedness Program grant referenced for communications and bystander care
- HRSA Model Trauma System Planning referenced
- Section 402 funds not specifically named
- Time Critical Diagnosis (TCD) system — "first in the nation law authorizing a time critical diagnosis system of care" (Introduction)
- State Advisory Council (SAC-EMS) — "perhaps one of the greatest strengths in the Missouri EMS system" (Resource Management)
- Cooperation between BEMS and Office of Highway Safety (Resource Management)
- Commitment of leadership, agencies, and providers (Introduction)
- 15 air ambulance providers with 45 aircraft providing statewide coverage within 30-minute radius (Transportation)
- Comprehensive air ambulance regulations developed through industry collaboration (Transportation)
- Missouri Foundation for Health support for assessment process (Acknowledgments)
- Hospital preparedness/MCI planning and EMSystem implementation (Communications, Resource Management)
- Pediatric equipment recognition program for ambulance services (Transportation)
- No statewide EMS plan
- No sustainable funding — "greatest threat" to trauma system
- Data reporting limited to less than 10% of call volume — "woefully inadequate"
- EMS "confederation rather than an EMS System"
- State EMS Medical Director position not in statute, funding ending 2012
- 911 system fragmentation — 17 counties without 911
- No standardized protocols or QI program
- 52% of land area beyond 60 minutes from Level I/II trauma center
- Southeast region without Level I or II trauma center
- Psychiatric patient transport identified as "the biggest transportation issue" (Transportation)
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
Time Critical Diagnosis (TCD) System — First in the Nation
The report identifies Missouri's TCD system as the first state law authorizing a time-critical diagnosis system of care encompassing trauma, stroke, and STEMI:
This first in the nation law authorizing a time critical diagnosis system of care." (Introduction, p.8)
The system was described as envisioned by the late Dr. Bill Jermyn. The TAT both praised the innovation and warned it could paradoxically undermine trauma system completion:
Although the novel TCD strategy is economically advantageous for overall EMS system development, the TCD strategy puts trauma system completion at some risk. Given limited workforce and time, emerging focus on STEMI and stroke may relegate trauma system development to a lower priority status." (Trauma Systems, p.38)
"Confederation" Rather Than a System
The TAT's characterization of Missouri as an "EMS confederation rather than an EMS System" (Resource Management) is a notable formulation. This language captures a structural observation — the existence of locally operated, independently governed ambulance districts without centralized coordination — that differs from the language used in other state assessments.
Missouri Foundation for Health as Critical External Funder
The assessment itself was funded by the Missouri Foundation for Health, not by state government. The State EMS Medical Director position was also externally funded by this foundation. The foundation's funding for the Medical Director was set to expire in 2012, creating a documented structural vulnerability. This degree of dependence on a private foundation for core EMS system infrastructure is unusual across the corpus.
Staff Reduction: 25 to 10
The Bureau of EMS lost 60% of its staff over the 16-year interval between assessments (from 25 to 10), with the reduction attributed to the recession and Missouri's "low tax-low service" orientation. The Trauma System Manager and EMS-C Coordinator positions were left vacant following the death of the employee who held both roles.
No Workforce Assessment Despite 17,000 Licensed EMTs
Despite having 17,000 licensed EMTs, the state had never performed a workforce needs assessment and had received "only sporadic reports of shortage of personnel." This differs from most other assessed states where workforce shortages are prominently documented.
NREMT Pass Rates Below National Average
Missouri's NREMT first-attempt pass rates were described as "well below the national average," triggering a progressive technical assistance program for underperforming training programs beginning in 2009.
Psychiatric Patient Transport
The report identifies psychiatric patient transport as "the biggest transportation issue," particularly in rural areas. This is a relatively uncommon finding in NHTSA assessments, which typically focus on trauma, cardiac, and stroke transport.
Air Ambulance Market Saturation
Missouri went from 1 air ambulance service in 1978 to 15 providers with 45 aircraft by 2010. The report noted "fierce competition and the lack of oversight and regulation could lead to compromising patient care and safety." Federal Airline Deregulation Act limitations on state regulation are documented.
Cross-State Trauma Care Without Repatriation
Missouri trauma centers provide care to patients from 8 surrounding states with no state-to-state repatriation agreements, though Illinois and Arkansas provide some compensation. The absence of repatriation creates an unfunded mandate on Missouri's trauma centers.
MARS as Surveillance Failure
The Missouri Ambulance Reporting System (MARS) is available free of charge and used by approximately 80% of agencies, yet collects only "life-threat" data (less than 10% of encounters). The report explicitly states it "cannot be used as a surveillance tool because it only captures a small fraction of the actual number of patient encounters." This represents a system where the infrastructure exists but is structurally hobbled by policy.
Patient Safety Organization Complication
The report documents an unusual complication: the effort to obtain peer-review protections through a Patient Safety Organization (PSO) "has potential to complicate the statewide evaluation process due to desire by some providers to only report patient care data to the PSO and not to the Bureau." This creates a scenario where the pursuit of QI protections could further fragment data reporting.
Regional Mismatch
Highway patrol and disaster response regions do not match EMS regions, a structural misalignment that complicates both organized medical response and joint grant funding applications.
Analysis produced using standardized NHTSA State EMS Assessment extraction framework. All quotes are from the Missouri 2010 Reassessment report. Sections A–I extracted from initial OCR text; Sections J (Evaluation) and K (Preparedness) extracted from supplemental RTF conversion. No editorial synthesis applied.
Montana
Full Analysis
Montana 1991 NHTSA Assessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of Montana
- Report type: Assessment (original, not reassessment)
- Date of site visit: June 25–27, 1991
- Year of publication: 1991
- Prior assessment year: N/A — this is the initial assessment
- TAT members:
- Matt Anderson (NREMT-P, Alaska Department of Health and Social Services)
- Kathleen A. Cline, MD, FACEP
- Valerie A. Gompf (NHTSA Highway Safety Specialist)
- Kevin K. McGinnis, MPS, EMT-Critical Care (Maine EMS Director)
- Joseph B. Phillips, Jr., MBA (Tennessee Division of EMS Director)
- William R. Schiller, MD, FACS
- Number of presenters/briefings: Over 35 presenters
- Requesting agency: Montana Highway Traffic Safety Division and Montana Department of Health and Environmental Sciences, Health Services Division, Emergency Medical Services Bureau
- Special acknowledgment: Drew Dawson, Chief, EMS Bureau; report notes "bold italics represent priority areas"
- Note: This is the baseline assessment against which the 2005 reassessment measured progress
SECTION 2: STATE CONTEXT
- Population (as cited in report): Fewer than six persons per square mile (specific population not stated)
- Geographic characteristics:
"Montana is a frontier state with fewer than six persons per square mile and a variety of colorful terrain ranging from the vast prairies of the East to the mountains of the Continental Divide in the West. The land area is over 147,000 square miles."
"Great distances, geographic barriers, and climate create a challenge to the delivery of Emergency Medical Services"
- Number of counties/jurisdictions: Not explicitly stated in report
- EMS system overview:
- Lead agency: Bureau of EMS, under the Department of Health and Environmental Sciences, Health Services Division
- Regulatory fragmentation: Board of Medical Examiners (personnel certification) and Board of Health (service/vehicle licensure, appeals) — separate from EMS Bureau
- ~4,000 prehospital providers (90% volunteers)
- 175+ emergency medical services statewide
| Category | Count |
|---|---|
| BLS ambulance services | 91 |
| Defibrillation ambulance services | 17 |
| Intermediate ambulance services | 6 |
| ALS (Paramedic) ambulance services | 5 |
| Fixed wing air ambulance | 5 |
| Rotor wing air ambulance | 5 |
| BLS non-transporting | 41 |
| Defibrillation non-transporting | 6 |
| Intermediate non-transporting | 1 |
| ALS non-transporting | 1 |
Personnel on ground ambulances:
| Level | Number |
|---|---|
| Advanced First Aid | ~750 |
| EMT-Basic | ~940 |
| EMT-D | ~230 |
| EMT-Intermediate | ~60 |
| EMT-Paramedic | ~25 |
| First Responder-Ambulance | ~35 |
| Registered Nurses | ~165 |
- No Level I trauma center and no medical schools in state
- 59 accredited hospitals (47 with fewer than 50 beds)
- Medical Assistance Facilities (MAFs) in extremely isolated areas
- No state EMS medical director (plans underway for part-time position)
- No trauma system — no enabling legislation, no designation
- No statewide data system — no mandatory data collection
- No triage/transport protocols statewide
- No hospital categorization
- 911 coverage: 70% of population (basic)
- No Emergency Medical Dispatch (EMD) training
- One active paramedic training program (~12 graduates/year)
- Average ambulance vehicle age: 10.9 years (range: months to ~30 years)
- Burn unit and hyperbaric facility: available centrally in state
- IHS hospitals/clinics: integrated into system, commended for ATLS mandate
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:
"comprehensive system planning and development has not been undertaken"
"There exist no statewide EMS data or QA/QI systems with which to provide information for planning purposes."
"There exists no centralized EMS system planning structure endowed with the authority to make rules and policy"
"Nor are there local or regional EMS planning/coordinating structures endowed with statutory authority"
(b) Specific data points:
- EMS legislation "does not address or define a complete EMS system"
- Existing state EMS plan: "has not been widely disseminated and is not well-understood at the provider level"
- No regional or local planning bodies with statutory authority
- Some county councils exist; professional organizations only informally involved
- EMS Bureau cannot monitor training or support it adequately
- Two organizational options presented in appendix: Advisory Council model vs. EMS Board model
(c) Report characterization: The TAT finds no systemic planning infrastructure at any level — state, regional, or local. This is a pre-system assessment: the pieces exist (providers, hospitals, air medical) but without organizational structure.
(d) Priority recommendation status: Yes — priority (bold italics). Comprehensive legislative authority, single EMS structure, regional/local planning bodies, and state EMS plan completion are recommended.
3B. Funding and Financial Sustainability
(a) Direct quotes:
"Funding for the EMS Bureau and system components is inadequate."
"The single greatest impediment to training in Montana is funding."
"Dedicated Montanans and organizations keep economically unfeasible, but medically effective services operational"
"the lack of billing by some services may decrease the resources available because much needed revenue for training, equipment, and maintenance is not recouped"
(b) Specific data points:
- No dedicated state EMS funding source
- Proposed: $5.00 vehicle registration fee (existing $1.00 abandoned vehicle fee cited as model)
- Two-mill levy recently authorized by legislature for ambulance services
- Many volunteer services do not bill Medicare/Medicaid at all
- Others charge "a fraction of the actual costs"
- Average ambulance age: 10.9 years (some nearly 30 years old)
- IHS replaces vehicles regularly through large-contract purchasing — cited as model
- No state subsidy for volunteer training
- No funding for state EMS medical director
- Trauma registry funding provided by Highway Traffic Safety
- No state funding for training programs
- CIT Foundation using NHTSA 402/403 funds for preventable death research
(c) Report characterization: The report includes a separate Appendix A on Financing — the only report in the corpus with a dedicated funding appendix. The TAT identifies failure to bill third-party payers as causing local taxpayers and donors to "subsidize the health care payment system" — a direct policy critique.
(d) Priority recommendation status: Yes — priority. Dedicated funding source ($5.00 vehicle registration fee), billing assistance, equipment grants, and training subsidies recommended.
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:
"Montana is fortunate to be endowed with an abundance of prehospital and hospital EMS resources. This is characterized by 4,000 prehospital providers, 90% of whom are volunteers"
"Volunteer recruitment and retention has been a problem... attributed to poor personnel management practices, low call volumes, stress burn-out, necessity for fund-raising and other non-EMS activities, and training/recertification requirements."
(b) Specific data points:
- ~4,000 prehospital providers; 90% volunteers
- One active paramedic program: ~12 graduates/year
- ~25 certified paramedics on ground ambulances
- EMT-Intermediate: relatively new, too early to judge spread
- First Responder-Ambulance level: 88 hours; Advanced First Aid: 54 hours — sub-EMT levels providing patient care
- Goal: all patients attended by at least one EMT by 1996
- No state funding for training
- No standardized instructor certification program
- No instructor monitoring by Bureau
- Highway Patrol: mandates First Responder training; refresher training inconsistent
- IHS: mandates ATLS within one year for physicians; PALS, ACLS courses
- No CISD system
- No EMS management training
- RNs considered EMT equivalents (new 1993 requirement for competency demonstration)
(c) Report characterization: The workforce is large relative to population but overwhelmingly basic-level and volunteer. With only ~25 paramedics statewide, ALS capability is extremely limited. The TAT's recommendation to evaluate whether "low volume, volunteer ambulance services" should convert to first-responder-only with "more regionalized ground and air transport" anticipates the 2005 report's endorsement structure by 14 years.
(d) Priority recommendation status: Yes — priority. Recruitment/retention programs, CISD, training subsidies, instructor certification, and nurse-to-EMT bridge courses recommended.
3D. Essential Service Designation
(a) Direct quotes: None directly addressing essential service designation.
(b) Specific data points:
- No discussion of EMS as essential service
- Services described as "economically unfeasible, but medically effective" — kept operational by volunteers
(c) Report characterization: Not addressed in 1991 assessment. EMS is described as a volunteer community service rather than a designated public utility.
(d) Priority recommendation status: Not documented.
3E. Regulatory Fragmentation
(a) Direct quotes:
"This fragmentation of responsibility for prehospital resource coordination, standard-setting, and enforcement has been compensated for by a current willingness to delegate extensively through the EMS Bureau."
(b) Specific data points:
- Board of Medical Examiners: personnel certification
- Board of Health: service/vehicle licensure, appeals
- EMS Bureau: monitoring, training support, system planning (inadequately resourced)
- Three-body regulatory structure acknowledged as fragmented
- "Current willingness to delegate" through Bureau compensates — TAT implies this is personality-dependent, not structural
- Fixed base operators transporting patients without EMS system oversight (excluded from licensing)
(c) Report characterization: The TAT identifies fragmentation across three bodies and recommends consolidation into a single structure. The reliance on "willingness to delegate" as the compensating mechanism is fragile — dependent on current relationships rather than statutory authority.
(d) Priority recommendation status: Yes — priority. Removing licensure/certification from Boards of Health and Medical Examiners and relocating within EMS Bureau recommended. This recommendation was not implemented — by 2005, the BOME split expanded rather than contracted.
3F. Data and Evaluation Systems
(a) Direct quotes:
"There is no comprehensive evaluation program that assesses the EMS system from a state level"
"There is no mandate that the reports be submitted for analysis."
"Montana has a state run report which could be a means of uniform data collection; however, many squads use other forms instead."
(b) Specific data points:
- State run report exists but: not mandatory, many services use other forms, reports often lost during hospital transfer
- No statewide EMS data system
- No QA/QI programs (except EMT-D audio tape audits — "particularly useful")
- Trauma Registry: not mandatory, excludes majority of transports, lacks prehospital data
- CIT Foundation conducting specific research projects — "not part of a comprehensive QA program"
- Three-year plan for comprehensive evaluation submitted to Highway Traffic Safety
- No QA/QI confidentiality protection
- No outcome data collection or assessment
(c) Report characterization: Complete absence of systematic data collection or evaluation. The EMT-D audio tape audit program is the sole bright spot — a micro-level QI initiative in a sea of no data.
(d) Priority recommendation status: Yes — priority. Comprehensive evaluation system, mandated standard reporting form, required data submission, QA/QI confidentiality protection recommended.
3G. Trauma System Status
(a) Direct quotes:
"There is no trauma system in Montana, and no legislation exists for trauma center designation or system development."
"There is no mandatory autopsy law for trauma deaths."
(b) Specific data points:
- No trauma system
- No enabling legislation
- No trauma center designation
- No triage/transfer protocols anywhere in state
- No transfer agreements between facilities
- No hospital categorization
- No mandatory autopsies
- Trauma Registry: software acquired, one-day training planned, not yet operational
- Development of Trauma Systems course planned for September 1991
- Critical Trauma Care Course sponsored by Bureau
- ATLS co-sponsored with Montana ACS Committee on Trauma
- Mobile trauma training system funded by Highway Traffic Safety
- CIT Foundation: NHTSA-funded preventable death study underway
- Patient referral: "based on established referral patterns" with "political overtones... resistant to change"
- COBRA compliance: "problematic"
- No Level I trauma center; no medical school
(c) Report characterization: This is a pre-trauma-system assessment. Montana in 1991 has no trauma infrastructure — no legislation, no designation, no protocols, no registry, no QI. The 2005 report would show enabling legislation (1995), four ACS-verified Level IIs, 51/63 facilities visited, and an operational (if voluntary) registry — representing substantial progress from this baseline of zero.
(d) Priority recommendation status: Yes — priority. Enabling legislation, trauma center designation, triage/transfer protocols, registry, autopsy mandate, and inclusive system recommended.
3H. Medical Direction
(a) Direct quotes:
"Current law does not mandate that all EMS services have a Medical Director."
"Basic services operate with little medical supervision, minimal quality assurance, and poorly defined accountability."
"There seems to be a shortage of Medical Directors. Most Medical Directors are volunteer or minimally compensated."
"plans are underway to create a part-time position" (state EMS medical director)
(b) Specific data points:
- No state EMS medical director (part-time position planned)
- Medical direction required only for EMT-I, EMT-P, and EMT-D programs
- BLS services: no medical director required; "little medical supervision"
- EMT-D program: most structured medical direction (mandatory QA, audio tape audits, Bureau reporting)
- Four physician advisory committees: EMT-D Committee, ACS Committee on Trauma, Montana Medical Society EMS Committee, Medical Directors' Task Force
- Statewide protocols developed by these committees but "not yet in uniform use"
- No training program or orientation for medical directors
- On-line medical direction: provided by physicians or nurses (unclear if nurses directing paramedics)
- Standing orders: liberal provisions, "nearly independent of on-line medical direction"
- Run reports: not routinely reviewed except for EMT-D
- No collaboration requirement between medical directors in multi-hospital communities
- Liability immunity statute: exists, may encourage participation
- No monitoring of standing order care quality
(c) Report characterization: Medical direction is voluntary, uncompensated, unmonitored, and inconsistent. The EMT-D program is the sole exception — its structured oversight (audio audits, medical director training, Bureau reporting) is described as a working model that could extend to other levels.
(d) Priority recommendation status: Yes — priority. All services should have a designated medical director; full-time state medical director; Medical Director Advisory Committee; defined responsibilities; administrative support from local services/hospitals recommended.
3I. Communications and Infrastructure
(a) Direct quotes:
"there is no comprehensive EMS telecommunications plan"
"Emergency Medical Dispatch training is not required for EMS dispatchers."
(b) Specific data points:
- 911 legislation enacted: $0.25/telephone fee for basic 911
- 70% of population served by 911 (basic); no E-911
- Lack of access in geographically isolated areas, "notably along the vast majority of Montana's major roadways"
- No standardized dispatch criteria for matching ALS response to need
- No EMD training (some dispatcher training planned, "undefined as to medical content")
- "Mutual Aid and Common Frequencies" publication exists — "more a historical and suggested... guide than... a planning document"
- VHF frequency congestion with aircraft and multiple vehicles with same identifiers
- No uniform EMS vehicle numbering system
- No telecommunications engineering assistance available
- DTMF encoding: meets current needs
- No requirement for recording/reviewing dispatch or ambulance-to-hospital transmissions
- Some services use crew paging with no scheduled personnel — contributes to longer response times
- Addressing/map-locator deficiencies compromise response
(c) Report characterization: Primitive communications infrastructure. No plan, no EMD, no E-911, no recording, no standards. The VHF frequency congestion and vehicle identifier confusion reflect a pre-modern system.
(d) Priority recommendation status: Yes. Comprehensive communications plan, EMD training, E-911 completion, engineering assistance, medical direction of dispatch, and frequency management recommended.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
N/A — this is the initial assessment. There is no prior assessment against which to measure progress.
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall System Characterization
"there is a functioning confederation of EMS providers and air-medical services that serve even the most remote areas of Montana"
"there is a strong commitment to quality EMS care, and the Team noted that the State is making vigorous efforts to provide quality care with the limited resources available"
"This report is provided in the spirit that the citizens of Montana will persevere and carry their system into a new era of development and integration."
The TAT characterizes Montana as a collection of dedicated individuals operating without a system. The word "confederation" — implying loose alliance rather than structured organization — is precise.
Structural Barriers Identified (1991 Baseline)
1. No comprehensive EMS legislation — law doesn't define a system
2. No state EMS medical director
3. No trauma system — no legislation, no designation, no protocols
4. No statewide data/evaluation system
5. No EMD training or dispatch protocols
6. No hospital categorization or triage/transfer protocols
7. No dedicated funding source
8. Three-body regulatory fragmentation (Bureau, Board of Medical Examiners, Board of Health)
9. 90% volunteer workforce with recruitment/retention challenges
10. Only ~25 paramedics statewide
11. No standardized instructor certification
12. No statewide communications plan
13. No transfer agreements between facilities
14. Vehicle fleet averaging 10.9 years
Greatest Strengths (as identified by the TAT)
- 4,000 dedicated providers in a frontier state
- IHS integration and ATLS mandate
- Medical Assistance Facilities in remote areas
- EMT-D program structure (medical direction, audio audits, QA)
- Rotor/fixed wing air medical coverage
- Good Samaritan law, Comfort One/DNR law, communicable disease protections
- CIT Foundation research capability
- Highway Patrol First Responder mandate
- EMS Bureau innovation in instructional technology
- Bureau staff dedication despite limited resources
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
Paired Assessment — 1991 Baseline for 2005 Reassessment
This is the first paired assessment in the corpus (Montana 1991 + Montana 2005), enabling direct longitudinal comparison over 14 years. Key trajectories:
| Category | 1991 Baseline | 2005 Status |
|---|---|---|
| Providers | ~4,000 (90% volunteer) | 5,000 (25% increase) |
| Trauma legislation | None | 1995 (unfunded) |
| Trauma centers | None designated | 4 ACS Level II, 1 Level III |
| State EMS medical director | None (planned) | None (still vacant) |
| Data system | None functional | None functional (new software failed) |
| 911 coverage | 70% basic | 100% basic, 62% E-911 |
| EMD | None | None |
| Statewide protocols | Developed but not uniformly used | BLS via BOME; no ALS baseline |
| EMS plan | Incomplete | Still incomplete |
| Communications plan | None | None |
| Triage/transfer protocols | None | None |
| Hospital categorization | None | Not completed (under development) |
| Regulatory structure | 3 bodies | 2 bodies (BOME/EMSTS split) |
The state EMS medical director, data system, EMD, EMS plan, and communications plan remain unfulfilled across the entire 14-year span. The trauma system shows the most dramatic progress (from zero to 4 ACS-verified Level IIs).
"Confederation" — Precise Institutional Characterization
The TAT's use of "confederation" to describe Montana's EMS system — a loose alliance of autonomous entities without central authority — mirrors the 2013 Florida ACS/COT language of "loose aggregation." Both describe systems composed of functional pieces without systemic integration.
90% Volunteer — Highest Rate in Corpus
Montana's 90% volunteer rate in 1991 is the highest documented in any report. Even Alaska's village ETTs and Iowa's declining volunteer workforce don't reach this proportion. Combined with only ~25 paramedics statewide, ALS capability was nearly nonexistent outside a handful of communities.
~25 Paramedics for 147,000 Square Miles
With approximately 25 paramedics serving ground ambulances across 147,000 square miles, Montana in 1991 had roughly one paramedic per 5,880 square miles. This may be the lowest paramedic density documented in any U.S. state assessment.
Appendix A: EMS Financing
Montana 1991 is the only report in the corpus with a dedicated financing appendix. Its practical guidance — bill Medicare/Medicaid, calculate actual costs, consider outsourcing billing to hospitals or private services — reflects a system where basic revenue cycle management was an educational need.
Organizational Options Appendix
The report includes two structural options (Advisory Council vs. EMS Board) as an appendix with organizational charts — the only report providing alternative governance models for the state to evaluate.
IHS as Model
The Indian Health Service is cited multiple times as a model: mandatory ATLS within one year, regular vehicle replacement through contract purchasing, injury prevention programs, and meeting state licensing standards. IHS integration is "commended" — a rare instance where a federal program within a state is held up as the standard.
Recommendation That Was Reversed
The 1991 TAT recommended removing licensure/certification from the Board of Medical Examiners and relocating it within the EMS Bureau. By 2005, the opposite occurred — the BOME expanded its EMS role by assuming licensing from the EMSTS Section. The 1991 recommendation was not only unimplemented but inverted.
EMT-D Program as Micro-System Model
The EMT-Defibrillation program — with its mandatory medical director training, audio tape audits, QA reporting, and Bureau oversight — functions as a proof-of-concept for structured medical direction within an otherwise unstructured system. It demonstrates that even in frontier Montana, systematic oversight was achievable when mandated.
TAT Member Continuity (1991 → 2005)
Kevin K. McGinnis and Joseph B. Phillips appear on both the 1991 and 2005 TATs — providing 14 years of institutional memory for the reassessment. McGinnis transitioned from Maine EMS Director (1991) to NASEMSD Program Advisor (2005).
Analysis completed per standardized NHTSA State EMS Assessment framework. No synthesis or editorial interpretation has been applied. Findings are extracted as documented in the report.
Full Analysis
Montana 2005 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of Montana
- Report type: Reassessment
- Date of site visit: June 21–23, 2005
- Year of publication: 2005
- Prior assessment year: 1991
"reviewed the progress since the 1991 Assessment"
- TAT members:
- Theodore R. Delbridge, MD, MPH, FACEP
- Christoph R. Kaufmann, MD, MPH, FACS
- Kevin K. McGinnis, MPS, WEMT-P
- Susan D. McHenry, MS (NHTSA facilitator)
- Joseph B. Phillips, MBA
- Drexdal R. Pratt, CPM
- Number of presenters/briefings: Over 30 presenters
- Requesting agency: Montana EMS and Trauma Systems (EMSTS) Section, Department of Public Health and Human Services (DPHHS)
- Special acknowledgment: Jim DeTienne recognized for "extraordinary efforts" in preparing briefing materials
SECTION 2: STATE CONTEXT
- Population (as cited in report): Less than one million (fewer inhabitants than the smallest states)
- Geographic characteristics:
"Geographically the fourth largest state in the country, it contains fewer inhabitants than the smallest of our states."
"six Montanans per square mile"
"From 1,800 feet of elevation to nearly 13,000, and from 117 degrees of blistering heat to -70 degrees of equally blistering cold"
Prairie in the east, mountains of the Continental Divide in the west. "Great distances, geographic barriers, and too few fellow EMS providers."
- Number of counties/jurisdictions: 56 counties; 58 PSAPs; 6 EMS regions
- EMS system overview:
- Lead agency: EMSTS Section, DPHHS (system planning, development, regulatory oversight)
- Board of Medical Examiners (BOME): Assumed personnel licensing/examination responsibilities in February 2004 — a major structural split
- 5,000 EMS providers (25% increase from 1991)
- Quick response units: 86 BLS, 12 intermediate, 20 ALS (non-transporting)
- Ambulance services: 76 BLS, 22 intermediate, 39 ALS
- Paid services: 10 private, 5 fire-based, 1 hospital-based; "all others are considered volunteer"
- Air medical: 4 rotor wing, 7 fixed wing (all but one hospital-based)
- Hospitals: 15 hospitals, 42 Critical Access Hospitals (CAHs), 3 Indian Health Service hospitals, 3 clinics (total 63 facilities)
- Trauma centers: 4 ACS-verified Level II, 1 Level III (self-designation system)
- No Level I trauma center — no burn unit in state (transfer to Salt Lake City or Seattle)
- No state EMS medical director
- No statewide EMS protocols (beyond BOME BLS standing orders)
- No regional medical directors
- No statewide EMS plan (under development)
- No functional EMS data system (software "never functioned as required"; rule not enforced)
- No statewide trauma triage or transfer guidelines
- EMS System Task Force: voluntary, quarterly, established early 2004
- Worker's compensation "insufficient" for volunteers
- License endorsement system: innovative tiered capability additions
- Notable demographic or socioeconomic factors cited:
"the lot of the paid or volunteer professional seems even more daunting when one considers great distances, geographic barriers, and too few fellow EMS providers"
Montana described as "frontier" — a classification beyond rural. IHS hospitals serve Native American populations. The Critical Illness and Trauma Foundation (CIT), based in Montana, contributed to the national Rural and Frontier EMS Agenda for the Future.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:
"there is a need for a comprehensive system for assessing, planning, developing, deploying and coordinating EMS resources"
"the state EMS plan has not been completed. This plan is needed to guide the process of developing and improving the system."
"the Section was unable to address many of the 1991 recommendations" due to "lack of funding and staffing limitations"
(b) Specific data points:
- 6 EMS regions (not aligned with trauma regions — alignment recommended)
- EMS System Task Force: voluntary, quarterly, established early 2004
- No completed statewide EMS plan (recommended in 1991, still incomplete in 2005)
- EMS/trauma region misalignment identified
- Strategic planning capacity freed by transfer of licensing to BOME
- TAT explicitly notes "fewer yet broader recommendations" compared to 1991's "many operational recommendations"
(c) Report characterization: The TAT acknowledges that the BOME split creates an opportunity for the EMSTS Section to refocus on system planning, but the absence of a completed statewide plan 14 years after the 1991 assessment represents a fundamental gap.
(d) Priority recommendation status: Yes. Completing the state EMS plan, recognizing EMSTS as lead agency, and aligning EMS/trauma regions are recommended.
3B. Funding and Financial Sustainability
(a) Direct quotes:
"As a result of the lack of funding and staffing limitations associated with increased workload demands, the Section was unable to address many of the 1991 recommendations."
"this is an ambitious goal given the limited staff currently available in the EMSTS Section"
"Enabling legislation was passed in 1995 to design, implement, and evaluate a trauma system for Montana. This legislation has not been funded adequately"
"The current worker's compensation system is insufficient because it does not place an appropriate value on volunteer labor."
(b) Specific data points:
- Trauma legislation (1995): not adequately funded; partial funding from 1997 legislature provides 1 FTE trauma system manager
- BOME: funded exclusively through licensure fees — limits investment in training
- Injury prevention position: federally funded (EMS-C), may end 2006
- No state EMS medical director funded
- No trauma system medical director funded
- No trauma registry manager funded
- Mobile trauma training unit: "nationally recognized" — discontinued
- STARS mobile education program: referenced
- Physician call pay: "expensive proposition for hospitals but is increasingly necessary"
- Neurosurgery coverage: insufficient even where hospitals pay call pay
- Volunteer services: inadequate worker's compensation, proposed volunteer income tax relief legislation
- Some services pay "full list price for everything from bandages to ambulances" — purchasing collective recommended
- Not all ambulance services bill third-party payers
(c) Report characterization: Funding inadequacy pervades every section. The 1995 trauma legislation was "not funded adequately" — a 10-year unfunded mandate at the time of assessment. The EMSTS Section's inability to address 1991 recommendations is directly attributed to funding/staffing limitations.
(d) Priority recommendation status: Yes. Legislative funding for state EMS medical director, trauma system medical director, trauma registry manager, trauma system implementation, worker's compensation reform, and statewide purchasing collective are recommended.
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:
"Montana today has 5,000 EMS providers, an increase of 25% since 1991."
"Volunteer recruitment and retention is widely regarded as a priority issue that must be addressed."
"Relatively unqualified physicians or physician assistants may be coerced to provide EMS medical direction as a matter of community service or a stipulation of their jobs."
"three quarters of EMTs and three quarters of RNs (who may be the first health professionals to provide care for the injured patient) have never had a basic trauma course" (western Montana)
(b) Specific data points:
- 5,000 EMS providers (up from ~4,000 in 1991)
- Vast majority of services are volunteer ("all others are considered volunteer" after 16 paid services identified)
- ALS not available 24/7 in all areas due to limited staff
- License endorsement system: innovative approach to expanding scope within tiers
- NREMT computer adaptive testing (CAT) planned for 2007
- 75% of EMTs and 75% of RNs in western Montana without basic trauma course
- No EMT scope authorization for hospital work (legislative recommendation)
- Mobile trauma training unit discontinued
- No statewide workforce health and safety program
(c) Report characterization: The 25% provider growth is celebrated, but the system remains overwhelmingly volunteer-dependent. The endorsement system — allowing licensed providers to add specific skills — is praised as innovative. The coercion of "relatively unqualified" physicians into medical direction roles is among the most candid workforce observations in the corpus.
(d) Priority recommendation status: Yes. Recruitment/retention programs, distance learning, mobile training, trauma education, EMT hospital authorization, and worker's compensation reform are recommended.
3D. Essential Service Designation
(a) Direct quotes:
"Montana's public service volunteers are an essential human resource whose value should be recognized in public policy."
(b) Specific data points:
- The Rural and Frontier EMS Agenda for the Future (NRHA 2004) is cited, including its "informed self-determination" model — community assessment of EMS performance and determination of desired service level
- No explicit "essential service" designation discussion
(c) Report characterization: The TAT does not directly address essential service designation. The "informed self-determination" framework is referenced as a model, which implicitly treats EMS service levels as community choices rather than mandated essential services.
(d) Priority recommendation status: Not documented as a recommendation. Absent from the report.
3E. Regulatory Fragmentation
(a) Direct quotes:
"The splitting of responsibilities between the EMS and Trauma Systems (EMSTS) Section and the Board of Medical Examiners (BOME) has created controversy and opportunity."
"there is confusion at the provider level as to each agency's role in providing the statewide EMS regulatory oversight"
"In the absence of a state EMS medical director, the Board is required to take a more hands-on role in providing medical direction."
(b) Specific data points:
- February 2004: BOME assumed licensing and examination from EMSTS Section — 2 positions transferred
- BOME: no EMS representative on the Board (legislative recommendation to add one)
- BOME: statutory authority for licensure AND training, but funded only through licensure fees
- EMSTS Section: retains system planning, development, regulatory oversight, data submission
- Dual authority: BOME (personnel) vs. EMSTS (system) — no state EMS medical director bridging them
- No formal lead agency recognition in statute for EMSTS Section
- Air medical services: unclear integration with EMS system; no dispatch/cancellation protocols; no BOME endorsement for air medical staff
(c) Report characterization: The 2004 BOME/EMSTS split is the defining regulatory event. The TAT characterizes it as creating both "controversy and opportunity" — an unusually balanced framing of what is clearly a problematic division. The absence of a state EMS medical director to bridge the two entities and the lack of EMS representation on the BOME are structural vulnerabilities.
(d) Priority recommendation status: Yes. EMS representative on BOME, formal lead agency recognition, state EMS medical director, and air medical integration are recommended.
3F. Data and Evaluation Systems
(a) Direct quotes:
"Montana's EMS system suffers from lack of meaningful evaluation."
"At the state level, evaluation is impossible because of a lack of data."
"the software to handle such data never functioned as required. Thus, the rule is not enforced and data is not submitted."
"beyond intuition or gestalt, it is difficult to say what in Montana EMS works well and what does not, and whether or not it is doing the job one might think it is."
(b) Specific data points:
- State data submission rule: exists but not enforced — software nonfunctional
- New web-based NEMSIS-compatible data system: under development, target Fall 2005
- Trauma registry: voluntary; Level II centers participating; paper-based CAH reports beginning
- No statewide EMS data available for analysis
- No clinical performance indicators
- No statewide QI program
- No response time data on a statewide basis
- Probabilistic linkage of multiple databases: previously demonstrated as feasible
- Preventable mortality studies: conducted occasionally
- Patient satisfaction: tracked sporadically by some services
- QI data: no legislative confidentiality protection
(c) Report characterization: This is the most data-poor system in the corpus. The TAT's language — "impossible," "suffers," "intuition or gestalt" — conveys a system operating without evidence. The nonfunctional software that led to unenforced data submission rules is a concrete failure mechanism. The TAT uses the same three-tier evaluation framework (structures/processes/outcomes) seen in the Florida 2013 report, delivered by the same lead author (Delbridge).
(d) Priority recommendation status: Yes. Data system deployment, mandatory submission, local evaluation facilitation, focused evaluation projects, QI confidentiality protection, and specific timelines are recommended.
3G. Trauma System Status
(a) Direct quotes:
"Montana, the 'Last Best Place', faces more challenges in trauma system implementation than almost all other states."
"It is because of these Montana 'trauma system pioneers' that the citizens of Montana enjoy the improvements in trauma care that are present today."
"Trauma center designation has been through self-designation alone."
"Triage and transfer guidelines do not exist and there is no current effort to write these important documents."
(b) Specific data points:
- Trauma legislation: 1995 (not adequately funded; partial 1997 funding)
- Trauma centers: 4 ACS-verified Level II, 1 Level III — all self-designated
- No Level I trauma center; no burn unit (transfer to Salt Lake City/Seattle)
- 63 total healthcare facilities (15 hospitals, 42 CAHs, 3 IHS, 3 clinics)
- 51 of 63 facilities visited by trauma system manager for consultation
- No statewide trauma triage criteria
- No statewide transfer guidelines
- No inclusive trauma system — no participation requirements for non-trauma-center facilities
- Trauma data: voluntary, Level II centers only; paper CAH reports beginning
- No system-wide QI process
- No trauma prevention programs from registry data
- No mandatory autopsies for trauma deaths
- Wyoming-Montana collaborative site visits: cited as potential national model
- Rocky Mountain Rural Trauma Symposium: annual
- 6 Regional Trauma Advisory Committees (RTACs) with good attendance
(c) Report characterization: The TAT balances admiration for "trauma system pioneers" against the reality of an incomplete trauma system. Self-designation only, no triage/transfer protocols, no inclusive system participation, and no adequate funding 10 years after enabling legislation. The Wyoming partnership is notable as a resource-sharing model.
(d) Priority recommendation status: Yes. Legislative funding, inclusive system participation, mandatory registry data, triage/transfer criteria, transfer agreements, trauma system medical director, registry manager, trauma education, autopsy mandates, and EMS/trauma region alignment are recommended — the longest recommendation set in this report.
3H. Medical Direction
(a) Direct quotes:
"Among the most embryonic features of Montana's EMS system is its manner of providing medical direction"
"At the state level, there is no state EMS medical director."
"There is no system of regional medical direction."
"Relatively unqualified physicians or physician assistants may be coerced to provide EMS medical direction as a matter of community service or a stipulation of their jobs."
"The less than desirable result is substantial heterogeneity in the availability and application of EMS medical direction."
"Others yearn for such involvement but only have access to physicians willing to provide the air of legality."
"there are others who feel fortunate to be free of an engaged EMS medical director and the potential additional accountability that might entail"
(b) Specific data points:
- No state EMS medical director
- No regional medical directors — no organization or formal communication among local MDs within 6 regions
- Medical direction mandated only for ALS or BLS-with-endorsement services
- BLS medical direction: provided de facto by BOME and its medical director subcommittee
- No EMS medical directors are full-time; "few are board certified in emergency medicine"
- No uniformly applied performance indicators or clinical care quality measures
- BOME developing Internet-based educational program for medical directors (partially complete)
- Limited liability protection exists for off-line medical directors; limited for on-line MDs not principally in ER/trauma
- Communications limitations affect on-line medical direction availability
(c) Report characterization: "Embryonic" is the TAT's characterization — the least developed medical direction system in the corpus. The spectrum from "active and qualified" to "air of legality" to "fortunate to be free" of medical direction is the most vivid description of medical direction heterogeneity in any report analyzed. The characterization of coerced, unqualified physician oversight as community service is remarkably candid.
(d) Priority recommendation status: Yes. State EMS medical director (legislatively established), regional medical director system, lines of authority, clinical performance indicators, medical director education, recruitment incentives, and BLS medical direction relationships are recommended.
3I. Communications and Infrastructure
(a) Direct quotes:
"Montana's EMS system still relies upon essentially the same communications system infrastructure that the TAT encountered in 1991."
"With aging mobile radios, towers and antennae, and hospital base stations, the system is at risk."
"There are no uniform statewide standards for PSAPs"
"there are no dispatch protocols, or emergency medical dispatch training or requirements"
(b) Specific data points:
- 9-1-1: 100% basic coverage; 62% E-911 (up from 70% basic in 1991)
- 58 PSAPs; 19 with E-911
- 37 PSAPs committed to E-911 and wireless E-911 in near future
- Cell phone coverage: primarily along major roadways; routing problems reported
- Physical addressing in rural areas: incomplete (privacy resistance)
- P25 infrastructure replacement: multi-million dollar build-out in capital area; $250,000 federal demonstration in northern tier
- P25 controversy: "top-down" planning, mixed-vendor interoperability failures, cost concerns, premature commitment debate
- FCC narrow-banding deadline: 2013 requires equipment replacement
- No statewide EMS communications plan (recommended in 1991, still absent)
- No PSAP standards (facilities, equipment, security, staffing, training)
- No emergency medical dispatch (EMD) protocols or training requirements
- VHF system: aging, supplemented by cell phones along highways
- HIRMS/OMAR: statewide health information and resource management system planned — "forward-thinking"
- No communications system quality improvement or infrastructure monitoring
(c) Report characterization: The communications system is essentially unchanged from 1991 — 14 years without modernization. The P25 controversy — top-down planning without provider buy-in, mixed-vendor failures, premature standards commitment — is the most detailed communications technology critique in the corpus. The absence of EMD is a recurring cross-state finding.
(d) Priority recommendation status: Yes. Statewide communications plan, P25 guidance, E-911/wireless-911 completion, PSAP standards, EMD provisions, HIRMS development, and communications QI are recommended.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (1991 Assessment)
A 14-year gap between the 1991 assessment and 2005 reassessment. The TAT provides scattered references to 1991 progress:
Completed:
- "The hospital should be easily accessible with its routes well-marked in every community" ✓
- Development of CAH/MAF as interval care provider ✓
- Alternative EMS licensing levels (endorsement system) ✓
- 9-1-1 coverage expansion (70% → 100% basic) ✓
Not completed (explicitly referenced):
- Statewide EMS communications plan ✗
- Air medical dispatch/cancellation protocols ✗
- PIEP program update and implementation ✗
- Newsletter/information dissemination ✗
- Ambulance vehicle operations courses ✗
- State EMS plan ✗
- Aggressive public information campaign ✗
- Various training improvements ✗
"the Section was unable to address many of the 1991 recommendations" — attributed to "lack of funding and staffing limitations"
The TAT explicitly frames this reassessment as offering "fewer yet broader recommendations" compared to 1991's "many operational recommendations, several of which were identified as a priority." This suggests a shift from specific operational fixes to systemic structural change.
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall System Characterization
"The majority of prehospital provider services rely on basic level volunteers, while a number of services provide paramedic level care around the clock. Bridging these are new capabilities afforded patients by a system of innovative licensure endorsements."
"No matter how daunting an environment they encounter at whatever level of the system, we are confident that those charged with organizing and providing Montana's EMS will innovate and persevere."
The introduction's tone — "austere beauty and remarkable contrasts" — frames Montana's challenges as inherent to its geography rather than institutional failure. The TAT expresses confidence in the people while documenting profound system-level gaps.
Structural Barriers Identified
1. No state EMS medical director — "embryonic" medical direction
2. No functional data system — evaluation "impossible"
3. BOME/EMSTS split — "controversy and opportunity," provider confusion
4. No statewide EMS plan — 14 years unfulfilled from 1991
5. No statewide protocols beyond basic BLS
6. No trauma triage/transfer guidelines
7. No EMD — no dispatch protocols, training, or requirements
8. Communications infrastructure unchanged since 1991 — aging, at risk
9. Inadequate funding — trauma legislation unfunded 10 years; EMSTS understaffed
10. Volunteer dependency — insufficient worker's compensation, recruitment/retention crisis
11. No EMS representation on BOME
12. Air medical services not integrated into EMS system
13. Self-designation only for trauma centers
14. 75% of western Montana EMTs/RNs without basic trauma education
Greatest Strengths (as identified by the TAT)
- 25% provider growth since 1991
- Innovative license endorsement system
- 4 ACS-verified Level II trauma centers (self-motivated verification)
- Wyoming-Montana collaborative trauma site visits
- Regional Trauma Advisory Committees with good attendance
- HIRMS/OMAR forward-thinking health information system
- CAH system providing emergency care waypoints
- 100% 9-1-1 basic coverage (up from 70%)
- EMS-C injury prevention program
- Critical Illness and Trauma Foundation national expertise
- Provider dedication acknowledged throughout
Most Critical Challenges
- "Embryonic" medical direction at every level
- Data system completely nonfunctional — "impossible" evaluation
- 14-year-old recommendations still unaddressed
- Overwhelmingly volunteer workforce with inadequate protections
- No statewide protocols, triage criteria, or transfer guidelines
- Communications infrastructure at risk of obsolescence
- Frontier geography with 6 persons per square mile
- 75% of western providers without basic trauma education
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
"Embryonic" — Strongest Medical Direction Characterization in Corpus
The TAT's use of "embryonic" for Montana's medical direction is the most severe characterization of any single system component across all reports analyzed. Idaho's 31-year medical director vacancy is longer, but Montana's system has no state medical director, no regional medical directors, no formal communication among local medical directors, and the spectrum from "active and qualified" to "air of legality" to "fortunate to be free" of oversight.
"Air of Legality" — Most Candid Workforce Description in Corpus
"Others yearn for such involvement but only have access to physicians willing to provide the air of legality."
This description of medical directors who provide nominal compliance rather than actual oversight is the most candid acknowledgment of performative medical direction in any report analyzed.
Data System Failure Mechanism
Montana is the only state where the data system explicitly "never functioned as required" — a software failure leading to rule non-enforcement leading to zero statewide data. Other states have incomplete data; Montana has none.
BOME/EMSTS Split — Unique Regulatory Structure
The 2004 transfer of personnel licensing to the Board of Medical Examiners while retaining system planning at EMSTS is unique in the corpus. No other state assessed has this specific bifurcation, though the split superficially resembles the tension between multiple agencies in other states (AHCA/DOH in Florida, regulatory boards elsewhere).
Frontier Classification
Montana's explicit use of "frontier" — distinct from "rural" — places it in a demographic category shared only with Alaska in the corpus. At 6 persons per square mile, the EMS challenges are qualitatively different from Iowa's rural landscape or Kentucky's Appalachian regions.
Wyoming Partnership
The Montana-Wyoming collaborative trauma site visit model is the only formal interstate cooperation for system development documented in any assessment. The TAT suggests it "could serve as a model for other adjoining states."
75% Without Trauma Education
The finding that 75% of EMTs and 75% of RNs in western Montana have "never had a basic trauma course" is the most specific and alarming education gap documented in the corpus.
"Informed Self-Determination" Framework
The report's citation of the Rural and Frontier EMS Agenda for the Future and its "informed self-determination" model — where communities assess their own EMS, learn alternatives, and choose investment levels — represents a philosophical approach to EMS service provision distinct from the essential service mandate advocated in other reports (especially Iowa).
Structures/Processes/Outcomes Framework — Origin Point
The Delbridge-authored structures/processes/outcomes evaluation framework appears here (2005) and in Florida (2013), suggesting it is a consistent analytical approach brought by this specific TAT member across assessments spanning 8+ years.
TAT Continuity
Theodore Delbridge appears on this 2005 Montana TAT and the 2013 Florida TAT. Drexdal Pratt appears on this 2005 Montana TAT and the 2013 Florida TAT. Susan McHenry facilitates both. Kevin McGinnis (NASEMSD) appears here, linking the state EMS directors' association perspective. This team composition likely influences the report's emphasis on system planning and lead agency authority.
Pre-NEMSIS Era
This 2005 report is contemporaneous with the early development of NEMSIS. Montana's data system aspirations are explicitly NEMSIS-compatible, but the system is pre-deployment. This temporal marker places Montana alongside Alaska (1999) as assessments documenting EMS systems before modern data infrastructure existed nationally.
Analysis completed per standardized NHTSA State EMS Assessment framework. No synthesis or editorial interpretation has been applied. Findings are extracted as documented in the report.
Nevada
Full Analysis
Nevada 2009 NHTSA EMS Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Nevada
- Report type: Reassessment
- Date of site visit: February 24–27, 2009 (cover page states Feb 24–27; body text states Feb 24–26)
- Year of publication: 2009
- Prior assessment year: 1991
- TAT members:
- Theodore R. Delbridge, MD, MPH, FACEP (Professor and Chair, Department of Emergency Medicine, East Carolina University)
- W. Dan Manz (Director, Emergency Medical Services Division, Vermont Department of Health)
- Susan D. McHenry (EMS Specialist, NHTSA — served as NHTSA facilitator)
- Terry J. Mullins, MBA (Chief, Bureau of EMS & Trauma System, Arizona Department of Health Services)
- Clay E. Odell, EMTP, RN (Trauma Coordinator, New Hampshire Department of Safety)
- NHTSA facilitator: Susan D. McHenry, EMS Specialist, NHTSA
- Number of presenters/briefings: The report states "many presenters from the State of Nevada" but does not provide a specific count.
- Requesting agency: Nevada Office of Emergency Medical Systems (OEMS), in concert with the Nevada Office of Traffic Safety (OTS)
SECTION 2: STATE CONTEXT
- Population (as cited in report): Clark County has "nearly two million people" compared to Eureka County with 1,500 (Introduction). No total state population is cited.
- Geographic characteristics: The report describes "great geographic and demographic extremes" — snow-capped mountains above 10,000 feet falling to deserts near sea level; two populous urban areas bordering "vast expanses of rural and frontier land"; a geographic area "large enough to encompass at least seven other states"; and towns with fewer than 100 people (Introduction). The state has 17 counties (implied by reference to Clark and Washoe plus "the other 15 counties").
- Number of counties/jurisdictions: 17 counties (implied: Clark, Washoe, and 15 others)
- EMS system overview:
- Governance structure: OEMS has a staff of 8 full-time equivalents and a general fund budget of approximately $700,000. A 9-member Committee on Emergency Medical Services (advisory, Governor-appointed) supports the OEMS. Counties with population over 400,000 (currently Clark County, potentially Washoe County) may establish their own parallel EMS regulatory structures. Clark County has its own Office of EMS under the Southern Nevada Health District.
- Number of agencies/providers: Approximately 90 permitted EMS agencies overseen by approximately 60 EMS medical directors (outside Clark County). 33 hospitals with emergency departments, including 11 Critical Access Hospitals. 4 ACS-verified and state-designated trauma centers. 3 rotor-wing programs (two with multiple aircraft), 2 fixed-wing programs. 6 EMS agencies operating at paramedic level outside metropolitan statistical areas.
- Notable demographic or socioeconomic factors cited: The extreme urban/rural divide — two urban centers vs. vast frontier. Many EMTs seek employment in casinos rather than EMS agencies. Primary physician count has declined 20% in the past two years. Nursing shortage cited as stressing hospital capacity for critical care transfers. Tourism economy referenced.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:The State lacks an EMS plan to guide next steps in developing systems that can best meet the needs of people with time sensitive injuries and illnesses." (Introduction)
The question of who bears what responsibility for blending the component parts into a cohesive whole is not fully defined." (Introduction)(b) Specific data points: No state EMS plan exists. The report does not reference any prior plan or any plan under development. (c) Report characterization: The absence of a state EMS plan is identified as a gap but not characterized with the same alarm as in some other reassessments. The TAT frames it as a necessary next step for a system at a "fork in the road." (d) Priority recommendation:
The OEMS should, with stakeholder input, establish, publish and update an EMS system plan.
3B. Funding and Financial Sustainability
(a) Direct quotes:The OEMS has a staff of eight full-time equivalents and a general fund budget of about $700,000." (Regulation and Policy, Status)
The Office exists without resources to support even a part-time physician medical director." (Regulation and Policy, Status)
The OEMS has not been given the staffing or financial resources identified as necessary in 1991 to achieve important objectives." (Introduction)
The size of the Nevada EMS system...all suggest that the system is under-resourced to meet the Legislature's intended declaration" (Regulation and Policy, Status)
The OEMS woefully lacks sufficient expertise and resources to begin the process of querying its database to glean the sort of information necessary to perform meaningful evaluations of the state EMS system." (Evaluation, Status)(b) Specific data points:
- OEMS general fund budget: approximately $700,000 (Regulation and Policy)
- OEMS staff: 8 full-time equivalents (Regulation and Policy)
- Clark County has its own Office of EMS that "closely parallels the functions, structure, staffing and budget of the State OEMS" — implying the state-level budget is being functionally duplicated at the county level (Regulation and Policy)
- No state funding for a physician medical director (Regulation and Policy)
The Health Division and the Nevada Legislature should ensure that the necessary funding and staffing support for the OEMS to achieve the objectives of the EMS system plan.
The Health Division should allocate funds to support a full-time data analyst and EMS system quality specialist within OEMS." (Evaluation)
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:Volunteerism appears to be on the decline in some of the State's most vulnerable and difficult to serve rural areas." (Introduction)
An analysis of certification and recertification data for EMTs suggests that the number of providers in Nevada is, at best, static or trending downward." (Resource Management, Status)
Many EMTs that achieve certification do not work for permitted EMS agencies. Instead they seek employment in non-clinical settings, primarily in casinos." (Resource Management, Status)
many rural EMS services are experiencing a critical loss of volunteer personnel. This is consistent with a national trend, but seems particularly acute in Nevada. There are reports of some services running with as few as four members." (Transportation, Status)
The numbers of both new students graduating from training programs and personnel recertifying are in a decline." (Human Resources, Status)
courses get cancelled as they cannot meet minimum enrollments of even 10 people." (Human Resources, Status)
here is continual flux as volunteer personnel may or may not be available in various areas, and ambulance services may not be able to answer calls due to lack of personnel. Currently, there is no way to assess how often that dynamic structure affects delivery of EMS." (Evaluation, Status)(b) Specific data points:
- Some services running with as few as 4 members (Transportation)
- Only 6 EMS agencies at paramedic level outside metropolitan statistical areas (Transportation)
- Courses cancelled below minimum enrollments of 10 people (Human Resources)
- The number of primary physicians has gone down by 20% in the past two years (Facilities)
- EMT numbers static or trending downward (Resource Management)
- Hospitals cannot hire/utilize EMTs for clinical care under Nevada law (Resource Management)
- Staffing with EMT-Basic and First Responder driver allowed by waiver in rural areas (Human Resources)
The OEMS should sponsor a dialogue with stakeholders to examine opportunities to stabilize the rural EMS workforce. No ideas should be excluded.
3D. Essential Service Designation
(a) Direct quotes:The current statute does not define which level of government is responsible for providing EMS and assuring qualified medical oversight. This is a glaring deficiency that leaves open questions about what responsibilities fall to state, county and local governments in assuring at least minimal EMS operations. These responsibilities need to be defined and enforced to avoid a future crisis in the availability of EMS to some communities." (Regulation and Policy, Status)(b) Specific data points: The report does not use the phrase "essential service." However, the TAT explicitly identifies the absence of governmental responsibility for ensuring EMS availability as a "glaring deficiency." (c) Report characterization: While not employing the "essential service" framework by name, this report addresses the underlying issue more directly than many others in the corpus — the question of which level of government bears responsibility for ensuring EMS exists. (d) Priority recommendation:
The Nevada Legislature should, through statute, clearly assign responsibility and authority for ensuring the availability of EMS within specific geopolitical boundaries." (Regulation and Policy)
This recommendation directly addresses the essential service concept without using the term.
3E. Regulatory Fragmentation
(a) Direct quotes:he 450B Statute is a provision that allows counties with a population of over 400,000 people to establish their own EMS regulatory structures, including the certification and licensing of EMS personnel and permitting of EMS agencies." (Regulation and Policy, Status)
Clark County has its own Office of EMS under the Southern Nevada Health District that closely parallels the functions, structure, staffing and budget of the State OEMS." (Regulation and Policy, Status)
he duplication and possibility of fragmentation for a statewide EMS system is concerning." (Regulation and Policy, Status)
he citizens of Nevada have developed in essence three separate EMS and trauma systems; one for Clark County, another for Washoe County and a third for the citizens of the other 15 counties." (Resource Management, Status)
Western and southern Nevada provide care for trauma patients in a vacuum with regards to one another. Each large metropolitan area controls its own health management authority over its trauma system. These systems are not uniformly over-seen by a state medical director or trauma advisory committee." (Trauma Systems, Status)
he statutory language does not clearly task OEMS with the full range of strategic system development and evaluation authorities necessary to ensure systems of care" (Regulation and Policy, Status)(b) Specific data points:
- Statutory threshold of 400,000 population for county self-regulation (Regulation and Policy)
- Clark County currently has parallel EMS regulatory structure; Washoe County may soon qualify (Regulation and Policy)
- In effect, 3 separate EMS and trauma systems operate: Clark County, Washoe County, and the remaining 15 counties (Resource Management)
- 90 permitted EMS agencies with approximately 60 medical directors outside Clark County (Medical Direction)
The Nevada Legislature should consider elimination of the large county authority for regulation of EMS activities in favor of true statewide standards.
The Nevada Legislature should update the Revised Statutes...The statute should include clear language that recognizes the OEMS as the lead agency for all aspects of EMS system design, implementation, regulation and evaluation.
3F. Data and Evaluation Systems
(a) Direct quotes:There is a statewide EMS patient care reporting system." (Introduction — noted as a positive development since 1991)
Approximately 95% of Nevada's EMS agencies submit data to the system, accounting for approximately 60% of the state's EMS responses. Some busier agencies do not yet submit data due to local software issues." (Evaluation, Status)
Nevada was among the early states to submit data to the National EMS Information System (NEMSIS)." (Evaluation, Status)
While data is being accumulated, representing more than 290,000 EMS responses so far, little information is available. The OEMS woefully lacks sufficient expertise and resources to begin the process of querying its database" (Evaluation, Status)
There are no statewide defined tracer conditions, evaluation priorities, or tools to help guide local evaluation efforts." (Evaluation, Status)
it is not possible to assess the effects of the statewide EMS system." (Evaluation, Status)
here is no statutory mandate or administrative code that speaks to the necessity and appropriateness of OEMS to be engaged in system evaluation." (Evaluation, Status)
here is no legal protection from discovery of peer-review information generated as part of evaluation efforts." (Evaluation, Status)(b) Specific data points:
- State data system: NEEDS (Nevada Electronic EMS Data System) — NEMSIS compliant (Evaluation)
- 95% of EMS agencies submit data (Evaluation)
- 60% of EMS responses captured (Evaluation)
- More than 290,000 EMS responses accumulated (Evaluation)
- No data analyst or quality specialist on staff (Evaluation)
- No QI peer-review legal protection (Evaluation)
- No statutory authority for state-level system evaluation (Evaluation)
- Trauma database does not capture data from non-designated hospitals or link with prehospital data (Trauma Systems)
The Health Division should allocate funds to support a full-time data analyst and EMS system quality specialist within OEMS.
The legislature, through statute, should authorize and direct OEMS to engage in ongoing and systematic evaluation of the statewide EMS system.
The legislature, through statute, should provide protections from discovery during civil proceedings of peer-review information generated during EMS quality improvement or evaluation initiatives.
3G. Trauma System Status
(a) Direct quotes:Western and southern Nevada provide care for trauma patients in a vacuum with regards to one another." (Trauma Systems, Status)
The trauma system does not currently include the frontier facilities. These frontier centers send patients to the trauma centers and receive little in return (i.e., education)." (Trauma Systems, Status)
Current data from trauma centers are not evaluated by a state QI committee to evaluate the trauma system's effectiveness." (Trauma Systems, Status)
A multi-disciplinary trauma committee with specialty representation including rehabilitation does not exist at the state level." (Trauma Systems, Status)
Rehabilitation centers are not involved as part of the Nevada trauma system or identified." (Trauma Systems, Status)(b) Specific data points:
- 4 ACS-verified and state-designated trauma centers: Level I, II, and III in Las Vegas (Clark County); Level II in Reno (Washoe County) (Trauma Systems, Resource Management)
- 4 hospitals with pediatric intensive care units (Resource Management)
- 1 burn center (Resource Management)
- 15 counties with no designated trauma centers (Trauma Systems)
- No Level IV trauma center designation process exists (Trauma Systems, Facilities)
- No state trauma advisory board (Trauma Systems)
- No state trauma medical director (Trauma Systems)
- Trauma participation is voluntary (Facilities)
- Trauma registry does not link with prehospital data or capture non-designated hospital data (Trauma Systems)
The Legislature should provide authority and funding for the OEMS to serve as the lead agency for the Nevada trauma system. Funding should support a trauma program director, a trauma registrar and a physician trauma medical director.
The Legislature should authorize a state trauma advisory board charged with providing recommendations to the Health Division on the development, maintenance and evaluation of a comprehensive state-wide trauma system.
The OEMS should implement level IV designation to encourage rural facilities to become a part of the statewide trauma system.
3H. Medical Direction
(a) Direct quotes:There is no state EMS medical director in Nevada. Thus, there is no physician to champion the clinical issues within the state's EMS system" (Medical Direction, Status)
here are approximately 60 EMS medical directors in Nevada who oversee the 90 permitted EMS agencies." (Medical Direction, Status)
here is no educational program or resource to help physicians acquire the necessary credentials of knowledge and familiarization. Nor is there a means of evaluating physicians' qualifications beyond their licensure." (Medical Direction, Status)
some physicians agree to serve as EMS medical directors out of a sense of obligation to their communities and recognition that they are among the few who are available. Again, that does not necessarily make them qualified." (Medical Direction, Status)
here is no incentive offered to EMS medical directors (beyond the reward of community service) or even protection from civil liability related to their roles." (Medical Direction, Status)
here is general acceptance that many of the proscribed functions of EMS medical directors are going unrealized." (Medical Direction, Status)
EMS medical directors perform in isolation. There is little to no collaboration with other medical directors, there is not a regular forum to become educated or resolve issues" (Medical Direction, Status)
Each EMS medical director has discretion to develop protocols for his/her EMS agency...There are no uniformly applied indicators of EMS system performance or clinical care quality." (Medical Direction, Status)(b) Specific data points:
- 0 state EMS medical directors (Medical Direction)
- Approximately 60 local EMS medical directors for 90 agencies outside Clark County (Medical Direction)
- 9 qualifications criteria for eligibility, but no educational program to help physicians meet them (Medical Direction)
- 10 statutory responsibilities assigned to medical directors (Medical Direction)
- No compensation, no liability protection, no evaluation mechanism (Medical Direction)
The State Legislature should establish, through statute, and fund the position of state EMS medical director
The State Legislature should establish, through statute, protection for EMS medical directors from civil liability arising from the performance of their associated duties.
3I. Communications and Infrastructure
(a) Direct quotes:Emergency communications is another example of the dichotomy of the EMS system in Nevada." (Communications, Status)
Nevada has almost universal access to 9-1-1. The urban areas enjoy enhanced 9-1-1 capability, while rural areas have basic 9-1-1 coverage at best." (Communications, Status)
most agencies utilize radio systems that are decades old and will soon be obsolete due to federal narrowbanding requirements." (Communications, Status)
Nevada has addressed this issue by supporting a study of EMS communications needs and the planned purchase of an 800 MHz radio system for each rural EMS agency and hospitals with an emergency department." (Communications, Status)(b) Specific data points:
- Almost universal 9-1-1 access; enhanced 9-1-1 in urban areas, basic in rural (Communications)
- Planned 800 MHz Nevada Shared Radio System (NSRS) via Nevada Department of Transportation (Communications)
- Funded through ASPR grant (Communications, Preparedness)
- Clark and Washoe Counties have incompatible radio systems requiring "hybrid" UHF/800 MHz interoperability solution (Communications)
- No specific PSAP count provided
- No statewide dispatcher training standards outside Clark and Washoe (Communications)
- Rural PSAPs are typically sheriff's departments with law enforcement dispatching priority (Communications)
The OEMS should work with the State's PSAPs to establish standards relating to EMS dispatch for 9-1-1 calls.
The OEMS should strongly encourage Clark County and Washoe County to proactively pursue the highest level of interoperability with EMS agencies utilizing the NSRS.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (Reassessment)
The report measures progress since the 1991 assessment. No formal numbered tracking of prior recommendations is provided.
Overall characterization of progress since 1991:Since the last EMS assessment in 1991, the Nevada EMS system has seen progress on several notable fronts." (Introduction)
Despite noteworthy progress, some of Nevada's highest peaks are shrouded in clouds." (Introduction)Documented as completed or improved since 1991:
- OEMS placed within Division of Health (characterized as "rational") (Introduction)
- Relationship with largest counties improved "through partnerships built on trust and mutual respect" (Introduction)
- Statewide EMS patient care reporting system (NEEDS) established, NEMSIS-compliant (Introduction, Evaluation)
- Preparedness initiatives "not even envisioned in 1991 are now maturing" (Introduction)
- Transition to NREMT certification with pass rates now meeting or exceeding national averages (Human Resources)
- Portable computer-based testing deployed to rural areas (Human Resources)
- Paramedic programs achieving or pursuing national accreditation (Human Resources)
- Trauma centers verified and designated (Introduction)
- Enhanced 9-1-1 in urban areas (Communications)
- NSRS radio system planned and funded (Communications)
- Significant preparedness coordination with OPHP (Preparedness)
- No state EMS plan (Introduction)
- OEMS not given staffing or financial resources identified as necessary in 1991 (Introduction)
- No state EMS medical director (Medical Direction)
- No statewide trauma advisory board (Trauma Systems)
- No Level IV trauma center designation (Trauma Systems, Facilities)
- Relationships between tertiary centers and community hospitals remain informal (Introduction)
- Rural workforce in decline (Introduction, Transportation, Human Resources)
- No assignment of governmental responsibility for EMS availability (Regulation and Policy)
- No QI peer-review legal protection (Evaluation)
- No statutory authority for system evaluation (Evaluation)
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization:The tone is measured, reflective, and diplomatic — notably more restrained than the Oregon 2006 or Kansas 2007 reassessments. The TAT uses geographic metaphor throughout:
The Silver State has reached a fork in the road. Any path forward has risks and could lead to a destination not currently on the map." (Introduction)
Despite noteworthy progress, some of Nevada's highest peaks are shrouded in clouds." (Introduction)
Nevada can decide to have a modern fully integrated statewide EMS system or it can choose to continue a path towards a series of related but different local or regional systems." (Introduction)
The TAT explicitly frames the state's central choice as a strategic decision rather than a failure to be corrected:
The realities of distance and resources will mean that different patients receive care more or less expediently. It does not need to mean that the care itself should be different." (Introduction)Structural barriers identified:
- Statutory provision for large-county self-regulation creating parallel/duplicate systems (Regulation and Policy)
- No statutory assignment of governmental responsibility for EMS availability — "glaring deficiency" (Regulation and Policy)
- Three de facto separate EMS/trauma systems (Resource Management)
- OEMS budget of $700,000 with 8 FTEs for the entire state (Regulation and Policy)
- No state EMS medical director and no funding for one (Regulation and Policy, Medical Direction)
- No statutory authority for system evaluation (Evaluation)
- No QI peer-review legal protection (Evaluation)
- Casino employment draining certified EMTs from EMS agencies (Resource Management)
- Hospital inability to hire EMTs for clinical care (Resource Management)
This is a notable report in the corpus for its framing evolution. The Background section references the 2006 IOM Report on the Future of Emergency Care and the concept of "regional accountable systems of care" rather than only the 1996 EMS Agenda for the Future. The updated 2009 reassessment standards explicitly reference "regionalized, accountable systems of emergency care" throughout. The OEMS is placed within the Health Division — a healthcare placement. The report's recommendations focus on specialty care regionalization (STEMI centers, stroke centers) alongside trauma, reflecting a healthcare integration framework.
However, the assessment was still requested through the Nevada Office of Traffic Safety and supported by highway safety funds.
Federal funding references:The report references ASPR (Assistant Secretary for Preparedness and Response) funding for the 800 MHz radio system (Preparedness, Communications). FLEX grants are mentioned for rural hospital trauma participation (Resource Management). EMS for Children federal funding is noted as supporting pediatric initiatives (Regulation and Policy). CDC Pandemic Influenza Planning grant is referenced (Preparedness). The Office of Traffic Safety is acknowledged for supporting NEEDS development (Evaluation). No Section 402 funds are cited by name.
Greatest strengths (as identified by the TAT):The leadership of the Health Division and the organizational structure down to the EMS Program Manager should be commended for having achieved more with less." (Regulation and Policy)
NEEDS data system — NEMSIS-compliant, early national adopter, 95% agency participation (Evaluation)
NREMT pass rates meeting or exceeding national averages (Human Resources)
Urban EMS systems "compare well with the best available anywhere in the country" (Introduction)
Preparedness coordination between OEMS and OPHP (Preparedness)
Operation Heartbeat public AED initiative (Public Information)
a spirit of cooperation coupled with a can-do attitude throughout the spectrum of the EMS system" (Introduction)Most critical challenges (as identified by the TAT):
- No governmental responsibility assigned for ensuring EMS availability — "glaring deficiency" (Regulation and Policy)
- Three separate de facto EMS systems with no unifying oversight (Resource Management)
- Rural workforce in "critical" decline with services running with as few as 4 members (Transportation)
- No state EMS medical director (Medical Direction)
- $700,000 budget with 8 FTEs for the entire state (Regulation and Policy)
- Data accumulated but not analyzed — "woefully" inadequate resources (Evaluation)
- No state trauma advisory board or statewide trauma QI (Trauma Systems)
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. "Glaring deficiency" — no governmental responsibility for EMS availability
The current statute does not define which level of government is responsible for providing EMS and assuring qualified medical oversight. This is a glaring deficiency that leaves open questions about what responsibilities fall to state, county and local governments in assuring at least minimal EMS operations.
The TAT's use of "glaring deficiency" to describe the absence of assigned governmental responsibility for EMS is one of the strongest single-issue characterizations in the corpus. The corresponding recommendation — to "clearly assign responsibility and authority for ensuring the availability of EMS within specific geopolitical boundaries" — is functionally an essential service recommendation without using the term.
2. The $700,000 budget figure
The OEMS general fund budget of approximately $700,000 with 8 FTEs is one of the few specific state EMS office budgets cited in the NHTSA assessment corpus. This provides a concrete data point for cross-state comparison and illustrates the resource constraints under which state EMS offices operate.
3. Casino employment drain
Many EMTs that achieve certification do not work for permitted EMS agencies. Instead they seek employment in non-clinical settings, primarily in casinos.
This is a uniquely Nevada finding. Certified EMTs choosing casino employment over EMS agency affiliation — combined with the statutory prohibition on hospitals hiring EMTs for clinical care — creates a paradox where trained personnel exist but are unavailable to the EMS system.
4. "Three separate EMS and trauma systems"
The TAT's characterization of Nevada as operating "in essence three separate EMS and trauma systems" — Clark County, Washoe County, and the remaining 15 counties — is a structural finding that goes beyond the typical fragmentation documented in other assessments. The statutory provision allowing large counties to create parallel regulatory structures makes this fragmentation legally sanctioned rather than merely organic.
5. Services running with 4 members
There are reports of some services running with as few as four members.
This is among the lowest service staffing levels documented in the NHTSA reassessment corpus and signals imminent service collapse in some rural areas.
6. Data collected but unanalyzable
The Nevada situation presents an unusual case: the state achieved 95% agency data submission and NEMSIS compliance with minimal resources, but then could not afford a data analyst to query the database. The report contains over 290,000 EMS responses that yielded essentially no information. This illustrates a specific failure mode — data infrastructure without analytical capacity.
7. 2006 IOM Report referenced in standards
This is one of the first NHTSA reassessments to reference the 2006 IOM Report on the Future of Emergency Care ("regional accountable systems of care") in its reassessment standards, signaling an evolution in the NHTSA framework from the earlier reliance solely on the 1996 EMS Agenda for the Future.
8. Physician supply decline
In the past two years the number of primary physicians has gone down by 20%.
A 20% decline in primary physician supply in two years is a striking finding that compounds the EMS medical direction challenges documented elsewhere.
9. Specialty center regionalization recommendation
The OEMS should convene a multidisciplinary stakeholder group to consider evidence-based regionalization of medical specialty centers, such as STEMI or stroke care centers, with prehospital triage and transport guidelines.
This recommendation — for regionalized specialty center designation beyond trauma (STEMI, stroke) — reflects the evolving post-IOM framework and is more forward-looking than typical NHTSA reassessment recommendations from this era.
10. Medical directors serving out of obligation vs. qualification
some physicians agree to serve as EMS medical directors out of a sense of obligation to their communities and recognition that they are among the few who are available. Again, that does not necessarily make them qualified.
The TAT's explicit distinction between obligation and qualification, stated with diplomatic bluntness, captures a rural medical direction dynamic that is implied but rarely stated this directly in other state reports.
Analysis extracted by standardized framework. No editorial synthesis applied. Page references correspond to section headings within the RTF document, as the source file did not contain consistent page numbering.
New Hampshire
Full Analysis
New Hampshire 2018 NHTSA Reassessment — Structured Analysis
CRITICAL NOTE ON DOCUMENT TYPE
This analysis is based on an Executive Summary compiled by the Bureau of Emergency Medical Services (dated December 7, 2018), NOT the full TAT report. The document contains Standards and Recommendations for each section but omits all Status narratives, data points, direct quotes from the TAT, progress on prior recommendations, and the introductory/contextual sections found in full NHTSA assessment reports.
As a result, this analysis is structurally incomplete compared to the other reports in the corpus. The recommendations can be extracted but the supporting evidence, system characterization, and TAT narrative cannot. Findings below are inferred from the recommendations only, which introduces a methodological limitation: the researcher can see what the TAT recommended but not why or what specific conditions prompted the recommendation.
The full TAT report may exist separately. If obtained, this analysis should be revised.
SECTION 1: REPORT IDENTIFICATION
- State: State of New Hampshire
- Report type: Reassessment
- Date of site visit: September 11–13, 2018
- Year of publication: 2018 (Executive Summary compiled December 7, 2018)
- Prior assessment year: Not stated in this document
- TAT members: Not listed in this document
- NHTSA facilitator: Not listed in this document
- Number of presenters/briefings: Over 20 presenters
- Requesting agency: New Hampshire Office of Highway Safety and the Division of Fire Standards and Training and Emergency Medical Services ("the Division")
SECTION 2: STATE CONTEXT
- Population: Not stated
- Geographic characteristics: Not described
- Number of counties/jurisdictions: Not stated
- EMS system overview:
- Lead agency: Division of Fire Standards and Training and Emergency Medical Services ("the Division") — housed separately from the Department of Health and Human Services (DHHS)
- Hospital oversight: DHHS (separate from EMS oversight by the Division)
- Reference to "Emergency Services Division" as a separate entity with successful systems of care implementation experience
- Reference to Granite State Healthcare Coalition
- Reference to 2016 ACS-COT trauma system review
- State EMS Medical Director position exists but responsibilities/authority not outlined
- State trauma program manager: position does not exist (recommended for funding/recruitment)
- State trauma registrar: position does not exist (recommended for funding/recruitment)
- Notable demographic or socioeconomic factors cited: Not described
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
Note: All findings below are inferred from recommendations only. No Status narratives exist in this document.
3A. Statewide EMS Planning
(a) Direct quotes: None available (no Status section)
(b) Specific data points: None available
(c) Report characterization: Not available
(d) Recommendations (from which gaps can be inferred):
- Prioritize 2016 ACS Systems Report recommendations, building toward a "statewide, mandated and inclusive trauma system"
- Develop comprehensive integrated transportation plan supporting trauma, stroke, and STEMI
- Define "appropriate facility" in administrative rules (current ambiguity exists)
- Define chain of communication between DHHS (hospital oversight) and the Division (EMS oversight) for trauma system oversight
Inferred gap: No statewide mandated inclusive trauma system exists. No comprehensive transportation plan for time-sensitive systems of care. Trauma system oversight is fragmented between DHHS and the Division.
3B. Funding and Financial Sustainability
(a) Direct quotes: None available
(b) Specific data points: None available
(c) Report characterization: Not available
(d) Recommendations (from which gaps can be inferred):
- "Develop a sustainable funding stream to support the trauma system"
- Fund and recruit State trauma program manager (1.0 FTE)
- Fund and recruit State trauma registrar (1.0 FTE)
Inferred gap: No sustainable trauma system funding stream. No dedicated trauma program manager or registrar positions exist.
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes: None available
(b) Specific data points: None available
(c) Report characterization: Not available
(d) Recommendations (from which gaps can be inferred):
- "Conduct a comprehensive statewide EMS workforce study to determine the status of the workforce, identify any gaps by geographical region" (appears in both Resource Management and Human Resources sections)
- Establish EMS Education Section within the Division; create EMS Education Manager position
- Require AEMT education through professional education organizations
- Review/revise instructor standards including sanctions for poor performance
- Establish RN-to-EMT licensure process with NREMT
- Utilize fire training/simulation facility for EMS programs
- Line of duty death benefits for all licensed EMS personnel including private and volunteer
Inferred gap: No comprehensive workforce study has been conducted. No EMS Education Section or Education Manager exists. No RN-to-EMT pathway. Instructor quality concerns. Volunteer and private EMS personnel excluded from line of duty death benefits.
3D. Essential Service Designation
Not addressed in this document.
3E. Regulatory Fragmentation
(a) Direct quotes: None available
(b) Recommendations (from which gaps can be inferred):
- Amend rules to authorize Division to sanction licensed EMS personnel for failing to comply with standards of care (authority does not currently exist)
- Strengthen Division authority through statute or rule to discipline providers
- No rules defining authority/recognition for Critical Care Paramedics and services
- Define chain of communication between DHHS (hospitals) and Division (EMS)
- Air ambulance compliance with statutes and rules including patient reporting is being pursued (not yet achieved)
- "De-conflict and streamline equipment requirements to reduce costs and administrative burdens for multi-level EMS agencies"
Inferred gap: The Division lacks authority to sanction personnel for standards of care violations. Disciplinary authority is insufficient. Critical care paramedicine is unregulated. Hospital and EMS oversight are split between two agencies without a clear communication chain. Air ambulance compliance is incomplete.
3F. Data and Evaluation Systems
(a) Direct quotes: None available
(b) Recommendations (from which gaps can be inferred):
- Pursue agreement with National Collaborative for Bio-preparedness for linking EMS, trauma, and crash data
- Staff dedicated to QI duties should analyze available data for transportation appropriateness
- Improve statewide participation with trauma registry data submission
- Continue/expand PI/CQI implementation efforts
Inferred gap: EMS, trauma, and crash data are not linked. Trauma registry participation is incomplete. QI analysis is not routinely performed.
3G. Trauma System Status
(a) Direct quotes: None available
(b) Recommendations (from which gaps can be inferred):
- Continue addressing 2016 ACS-COT review recommendations
- Require all New Hampshire hospitals to seek State trauma center designation (not currently required)
- Develop trauma system ensuring patients transported only to designated centers
- Require Level III centers to be ACS verified (currently not required)
- State should continue designating/verifying Level IV centers
- Fund trauma program manager (1.0 FTE) and trauma registrar (1.0 FTE) — neither position exists
- Require designated trauma centers to contribute data to State registry (not currently required)
- Develop sustainable trauma system funding
Inferred gap: Not all hospitals are designated trauma centers. Trauma patients are being transported to non-designated hospitals. Level III centers are not ACS verified. No dedicated trauma program manager or registrar. No mandatory trauma registry data submission. No sustainable trauma funding.
3H. Medical Direction
(a) Direct quotes: None available
(b) Recommendations (from which gaps can be inferred):
- Outline responsibilities and authority of State EMS Medical Director (not currently defined)
- Position should be "adequately compensated"
- Could be expanded to include Preparedness and other DHHS medical oversight
- If expanded, position should be shared between DHHS and Division
- Provide legal protection for medical directors for EMS activities (not currently in statute or rule)
- Leverage State EMS Medical Director role for preparedness activities
Inferred gap: State EMS Medical Director responsibilities/authority are not outlined. Compensation may be inadequate. No legal protection for medical directors' EMS activities exists in statute or rule.
3I. Communications and Infrastructure
(a) Direct quotes: None available
(b) Recommendations (from which gaps can be inferred):
- Seek input from Emergency Services Division on successful systems of care implementation
- Engage Emergency Services Division as advocate for systems of care development
- Work with Emergency Services Division to analyze available data for patient flow, transportation, and EMS operations "to gain situational awareness regarding the status of New Hampshire's system of care"
Inferred gap: The Division appears to lack "situational awareness" regarding patient flow and system operations. The Emergency Services Division (a separate entity) has implemented other systems of care successfully, suggesting the EMS/trauma division has not.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
Not documented. The prior assessment year is not stated, and no progress tracking is included.
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Tone Assessment
The Executive Summary format eliminates the TAT's narrative voice entirely. No introduction, no literary framing, no characterization of strengths or challenges, no commendations. This is the only document in the corpus that is purely a list of standards and recommendations without contextual narrative.
Structural Barriers (Inferred from Recommendations)
1. Split oversight — DHHS oversees hospitals; the Division oversees EMS; no clear communication chain
2. Division lacks disciplinary authority — cannot sanction personnel for standards of care violations
3. No trauma system infrastructure — no trauma program manager, no registrar, no mandatory designation, no mandatory registry participation, no sustainable funding
4. No workforce data — comprehensive study never conducted
5. No EMS Education Section — within the Division
6. No medical director legal protection — in statute or rule
7. State EMS Medical Director role undefined — responsibilities and authority not outlined
8. Air ambulance non-compliance — with existing statutes and rules
9. Critical care paramedicine unregulated
10. Data systems not linked — EMS, trauma, and crash records separate
Lead Agency Placement
The Division of Fire Standards and Training and Emergency Medical Services is a combined fire/EMS entity separate from DHHS (which oversees hospitals). This is a distinctive governance structure — EMS housed with fire services rather than with public health or as an independent board.
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
Executive Summary Format — Unique in Corpus
This is the only document in the corpus that is an Executive Summary rather than a full TAT report. The absence of Status sections eliminates the evidentiary foundation for all recommendations. This format decision may itself be a data point — the Bureau compiled and distributed the summary, potentially controlling the narrative by omitting the TAT's detailed system characterization.
Most Underdeveloped Trauma System in Corpus
Based on the density of foundational trauma recommendations (no mandatory designation, no mandatory registry, no program manager, no registrar, no sustainable funding, no ACS verification for Level III, patients transported to non-designated hospitals), New Hampshire appears to have the least developed trauma system in the corpus. All other states analyzed have at least some of these elements in place.
Split Fire/EMS and Health Agency Oversight
The Division of Fire Standards and Training and Emergency Medical Services housing EMS with fire services rather than health/public health is the only such arrangement in the corpus. Every other state analyzed places EMS oversight within a health-related agency: Department of Public Health (Georgia, Iowa), Department of Health and Social Services (Alaska), Department of Health and Welfare (Idaho), or an independent board with health mission (Kentucky).
"Gain Situational Awareness"
The Communications recommendation to "gain situational awareness regarding the status of New Hampshire's system of care" is a striking admission — it implies the Division does not currently have a clear picture of how its own system functions.
Line of Duty Death Benefits Gap
The recommendation to extend line of duty death benefits to "all licensed EMS personnel including privately employed and volunteer personnel" implies these personnel are currently excluded — a workforce equity issue not documented in other reports.
2016 ACS-COT Review
The report references a 2016 ACS-COT trauma system review, suggesting external assessment had already identified system gaps two years prior to this NHTSA reassessment. The TAT recommendation to "continue to address" those recommendations implies they remain unimplemented.
Recommendation Density
Despite being the shortest document in the corpus, the recommendations reveal a system with more foundational gaps than any other state analyzed — lacking basic infrastructure (trauma manager, registrar, workforce data, disciplinary authority, medical director definition) that other states, even those with significant challenges, already have in place.
Analysis completed per standardized NHTSA State EMS Assessment framework. This analysis is limited by the Executive Summary format of the source document, which contains only Standards and Recommendations without Status narratives, data points, or TAT characterizations. Findings are inferred from recommendations where noted. The full TAT report, if obtained, should replace this analysis.
Ohio
Full Analysis
Ohio 2011 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Ohio
- Report type: Reassessment
- Date of site visit: February 15–17, 2011
- Year of publication: 2011
- Prior assessment year: 2001 (Background, p.4: "reviewed the progress since the 2001 Reassessment")
- TAT members:
- D. Randy Kuykendall, MLS, NREMT-P
- W. Dan Manz
- Susan D. McHenry, MS
- Curtis Sandy, MD, FACEP
- Jolene R. Whitney, MPA
- NHTSA facilitator: Susan D. McHenry, MS (listed as TAT member; no separate facilitator distinguished)
- Number of presenters/briefings: Over 20 presenters over the first day and a half (Background, p.4)
- Requesting agency: Ohio Department of Public Safety, Division of Emergency Medical Services (OEMS)
SECTION 2: STATE CONTEXT
- Population (as cited in report): 11.5 million — "the nation's seventh most populous state" (Introduction, p.8)
- Geographic characteristics: Blend of "livable mid-size cities to beautiful rural countryside" (Introduction, p.8); challenges of "population density disparity" and geography (Trauma Systems, p.39)
- Number of counties/jurisdictions: 88 counties (Communications: enhanced wireline 9-1-1 in 88 counties)
- EMS system overview:
- Governing body: State Board of Emergency Medical Services (20 members, appointed by Governor with Senate concurrence, three-year terms)
- OEMS also serves as lead agency for fire service training and certification
- 10 prehospital EMS regions with Regional Physician Advisory Boards (RPABs)
- Over 42,000 certified EMS personnel; over 42,000 certified firefighters; over 10,000 certified fire safety inspectors
- 93 institutions approved to offer EMS training
- Separate Ohio Medical Transportation Board (OMTB) regulates private-for-profit EMS agencies
- Notable demographic or socioeconomic factors cited: Economy described as "a diverse mix of agriculture, manufacturing and service industries" (Introduction, p.8). No specific socioeconomic data cited.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:The EMS Board is charged with the preparation of a statewide emergency medical services plan and a plan for the statewide regulation of emergency medical services during periods of disaster." (Regulation and Policy, p.12)
The EMS Board has established a Strategic Planning Committee to develop a 5-year plan for the advancement of Ohio's EMS system. All current committees of the Board have completed a S.W.O.T. analysis and submitted goals." (Regulation and Policy, p.13)(b) Data points: The EMS Board is statutorily required to prepare a statewide EMS plan. A Strategic Planning Committee exists and a 5-year plan is under development. The TAT recommendations were to be incorporated into the plan. A trauma-specific framework document ("A Framework for Improving Ohio's Trauma System") was approved by the EMS Board in October 2010. (c) TAT characterization: Planning activity is acknowledged as underway. The TAT noted "lack of a state trauma plan" among the challenges (Trauma Systems, p.39). (d) Priority recommendation: The OEMS and EMS Board should complete their strategic planning process with the inclusion of TAT recommendations. The Ohio Trauma Plan should be completed and implemented.
3B. Funding and Financial Sustainability
(a) Direct quotes:The primary funding source for the OEMS and the EMS Board is safety belt violation fines. Due to increase in safety belt use rates (a good thing) this revenue source is decreasing (a bad thing)." (Regulation and Policy, p.10)
The increased use of safety belts and corresponding decrease in revenues from fines are threatening the financial viability of the EMS system infrastructure." (Introduction, p.8)
Sixty cents of each fee has been designated for the EMS and Trauma fund. The money generated through this fee has been sufficient to maintain operations however a recent challenge has been made to the collection of the fee which is concerning as it could result in a loss of the funds in the future." (Regulation and Policy, p.10)
The net result is that the Division and the EMS Board are under resourced to fulfill their legislatively assigned functions." (Regulation and Policy, p.10)
The strategy Ohio has used for its funding sources makes good sense but has created instability in support due to a declining base of fines collected." (Regulation and Policy, p.10)(b) Data points:
- Primary funding: safety belt violation fines (declining)
- Supplemental funding: $0.60 fee on driving abstracts designated for EMS and Trauma fund (legal challenge pending)
- Over 700 EMS agencies benefit annually from Ohio EMS grant support
- Grant priorities codified in Ohio Revised Code: (1) EMS training/equipment, (2) trauma system injury prevention, (3) trauma rehabilitation, (4) trauma procedures research
- Since 2003–2004, over $2.2 million awarded in injury prevention grants (second priority category)
- $350,000 in Section 408 grant funding from Ohio Office of Traffic Safety for trauma registry upgrade
- No dedicated funding source to offset uncompensated trauma care at hospitals
- EMS Board and OEMS should work with Legislature to identify a stable and ongoing source of funding
- Legislature should create a trauma fund to partially compensate verified trauma centers for unreimbursed care
- Establish a graduated fee schedule for EMS organization licensure and ambulance permits
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:In 1992, there were approximately 34,000 certified EMTs at all levels in Ohio. Today, there are over 42,000 EMTs." (Human Resources, p.21)
The most noticeable change has occurred at the Paramedic level jumping from approximately 6,000 certified in 1992 to over 16,000 today." (Human Resources, p.21)
Rural areas with volunteers were reported to be having more trouble recruiting and retaining personnel." (Human Resources, p.21)
Some volunteer agencies report using their grant money to pay for personnel to complete additional training only to have those personnel move to the urban and metropolitan areas in search of jobs once their training is complete." (Human Resources, p.21)
Although a needs assessment has not been completed, Ohio has served as a training ground for many other states." (Human Resources, p.21)(b) Data points:
- Over 42,000 certified EMS personnel (up from 34,000 in 1992)
- ~16,000 certified paramedics (up from ~6,000 in 1992)
- ~21,500 EMT-Basics (down slightly from ~24,000 in 1992)
- ~2,100 First Responders (level added in 2000)
- ~4,000 initial certifications and ~10,000 renewals processed annually
- Three-year certification renewal cycle
- Over 3,600 EMS, Assistant EMS and Continuing Education instructors certified
- Over 500 institutions awarded Certificates of Approval for continuing education
- 93 institutions approved for EMS training; only 5 of 51 paramedic programs hold CAAHEP accreditation
- CAAHEP accreditation required for all paramedic programs by January 1, 2018
- Tennessee example: ~75% of 150 new paramedics hired came from Ohio
- Conduct a formal needs assessment of numbers, levels, and placements of EMS personnel
- Reform Ohio "accreditation" process into a State approval process working with national CAAHEP accreditation
- Support initial cost of paramedic program accreditation with EMS grant funds
3D. Essential Service Designation
(a) Direct quotes: Not documented in this report — the term "essential service" does not appear. (b) Data points: Not addressed. (c) TAT characterization: Not addressed. EMS is described within the framework of certified personnel, licensed agencies, and regulated services. (d) Priority recommendation: Not recommended.3E. Regulatory Fragmentation
(a) Direct quotes:The State's lead agency does not have clear uniform regulatory authority over all forms of EMS agencies and vehicles." (Introduction, p.8)
Having a separate Medical Transportation Board that regulates predominately private-for-profit EMS agencies is an anomaly." (Regulation and Policy, p.14)
There appears to be some confusion and duplication of effort by having two boards regulate the provision of emergency medical services within Ohio." (Transportation, p.24)
Seventy percent of the ambulance services in Ohio are fire based and are not state regulated." (Transportation, p.24)
Due to the existing bifurcated system of ambulance service regulation, the OEMS is unable to determine the numbers and locations of ambulance service assets across the state." (Resource Management, p.17)
Similar 'home rule' excuses pervaded many presentations to the TAT when there appeared to be a common understanding about why OEMS is unable to enforce requirements that are clearly the right thing for EMS patients." (Regulation and Policy, p.14)(b) Data points:
- Two regulatory boards: State Board of EMS and Ohio Medical Transportation Board (OMTB)
- OMTB annually licenses 443 EMS organizations, 133 MICUs, inspects 3,200 vehicles
- 70% of ambulance services are fire-based and NOT state regulated
- 15 licensed air ambulance services with 57 helicopters — no certificate of need, no central dispatch, no standardized activation guidelines, no CAMTS accreditation required
- 10 EMS regions; Region 6 has not had an active RPAB "in several years"
- EMS Board has 20 members; Trauma Committee has 22 members plus 3 liaisons (described as "may be too large to be practical")
- OEMS cannot determine the total number of EMS organizations and vehicles statewide
- No mechanism to enforce agency medical director notification requirement
- No accurate database of medical directors exists
- Legislature should reassign functions/authorities/resources of OMTB to OEMS — "a step towards achieving a single lead EMS agency in Ohio"
- Legislature should establish authority for OEMS to require ALL EMS agencies to be licensed and inspected
- Legislature should authorize OEMS to establish regulations for ALL ground and air ambulances
- EMS Board should re-evaluate the map and functions of EMS regions
- Director of Public Safety and EMS Board should clarify supervisory hierarchy of Executive Director to establish single point of oversight
3F. Data and Evaluation Systems
(a) Direct quotes:The State holds a rich repository of EMS and trauma care data that has not yet been fully transformed into useful information for guiding further policy development." (Introduction, p.8)
The lack of authority to submit Ohio's substantial pre-hospital database into the National EMS Information System (NEMSIS) represents a missed opportunity for both Ohio and the nation." (Regulation and Policy, p.14)
Ohio does not submit to the national EMS database (NEMSIS) over concern of an Ohio law addressing release of medical information that tends to reveal patient identity." (Evaluation, p.44)
The use of these databases by the OEMS and the EMS Board has been limited mainly due to the lack of personnel to analyze the data. When benchmarked against other states, the OEMS lacks the human resources to optimally analyze the acquired data." (Evaluation, p.44)
Currently, there is no mechanism to monitor compliance with the data submission requirement nor is there provision for enforcement but the OEMS reports around 85% of all patient encounters are submitted." (Evaluation, p.44)(b) Data points:
- Two legislatively created databases: EMS Incident Reporting System (EMSIRS) and Ohio Trauma Registry (OTR)
- EMSIRS transitioning to NEMSIS V2 compliance
- ~85% of patient encounters submitted (ground transport only; does not include first responder or air medical services)
- EMSIRS data NOT submitted to national NEMSIS database due to Ohio privacy law concerns
- Trauma Registry collects data on admissions >48 hours, transfers, and deaths
- Trauma rehabilitation registry established 2005 — "first of its kind in the nation" — data not yet linked to acute care data for meaningful analysis
- $350,000 Section 408 grant funding for trauma registry upgrade to NTDS compliance
- OEMS publishes annual benchmark reports with regionalized time intervals and procedure success rates
- EMS peer-review and QA process protected from discovery for liability purposes
- Ohio participates in Traffic Records Coordination Committee
- CODES program planned for future data linkage
- Grants provided to EMS agencies to facilitate EMSIRS access
- Require all hospitals to submit trauma registry data
- Provide funding for additional staff for data analysis
- Seek legal clarification to submit EMSIRS data to NEMSIS and trauma data to NTDB
- Increase analysis of database information to drive system design
- Resolve confidentiality issues restricting access to de-identified data
- Regularly provide reports to hospitals and EMS providers
3G. Trauma System Status
(a) Direct quotes:One of the recognized shortcomings of the current Ohio trauma system is that it is 'exclusive'; it focuses exclusively on the severely injured patient rather than all injured patients and is centered exclusively on hospitals verified by the ACS as trauma centers rather than all hospitals who may receive injured patients." (Trauma Systems, p.39)
The forty-five verified trauma centers in Ohio are self-selected and undergo voluntary verification by the American College of Surgeons. There was no state needs assessment to determine the optimal level, number, and location of trauma centers; neither is there a state designation process." (Trauma Systems, p.40)
This non-ideal geographic distribution leaves nearly 4% of the Ohio population more than one hour away from definitive care at a Level I or II trauma center, whether by ground or air transport." (Trauma Systems, p.40; citing American Trauma Society TIEP 2009 data)
Only a lead agency that monitors patient care and transfer, has designation and de-designation authority over trauma centers, and has approval authority for triage protocols can be expected to successfully implement a comprehensive and integrated inclusive trauma system." (Trauma Systems, p.40)(b) Data points:
- Mandated statewide trauma system established by legislation in July 2000
- 45 verified trauma centers (voluntary, ACS verification exclusively):
- 13 Level II (including 3 pediatric Level II)
- 18 Level III
- No Level IV or Level V trauma centers (ACS does not verify these levels; state has no criteria)
- 9 burn centers, including Shriners' Hospitals for Children in Cincinnati
- 181 hospitals with 33,860 beds statewide
- Verification entirely voluntary — no state designation or de-designation authority
- No state needs assessment for optimal trauma center number/location
- Nearly 4% of population more than 1 hour from Level I/II trauma center
- No dedicated funding for uncompensated trauma care
- "A Framework for Improving Ohio's Trauma System" approved October 2010
- Trauma rehabilitation registry established 2005 (first in nation)
- 22-member Trauma Committee plus 3 liaisons
- Trauma Visionary Committee established to develop Ohio Trauma Plan
- No State Trauma Medical Director
- Legislature should modify legislation for an inclusive trauma system with Level IV (and possibly Level V) centers
- Create and fund the position of State Trauma Medical Director (at least 0.25 FTE, trauma/critical care surgeon)
- Complete and implement the Ohio Trauma Plan
- Provide additional FTEs for the OEMS trauma program
- Develop strategies for all hospitals to submit trauma data
- Work with Attorney General to authorize publishing aggregate data and submitting to NTDB and NEMSIS
- Develop evidence-based injury prevention and control plan
3H. Medical Direction
(a) Direct quotes:The State EMS Medical Director is a contract position designated in Ohio law and must be a board-certified emergency medicine physician in active practice and actively involved in EMS for at least 5 years." (Medical Direction, p.36)
The State EMS Medical Director however, has limited authority in regards to agency medical directors and has limited involvement with air medical transport within the state." (Medical Direction, p.36)
The State EMS Medical Director for the past several years provides many hours of service beyond what her contract provides and is recognized at a national level for her contributions." (Medical Direction, p.36)
Currently, the OEMS does not have an accurate database of medical directors as there is no mechanism to enforce the agency notification requirement." (Medical Direction, p.37)
The RPAB cannot however serve as a 'regional medical direction' board because of liability concerns." (Medical Direction, p.37)(b) Data points:
- State EMS Medical Director: EXISTS — contract position, designated in law (Dr. Carol Cunningham)
- 10 RPABs with members serving 3-year terms, meeting 4 times/year
- Region 6 RPAB inactive for several years (rural, large geographic area, no regional referral center)
- Agency medical directors must be board-certified or board-eligible in emergency medicine
- If not board-certified/eligible in EM: must complete NAEMSP Medical Director Course or Ohio ACEP on-line course — no mechanism to track completion
- Medical directors have civil liability protection (except willful/wanton misconduct) but NO administrative liability protection
- RPABs limited to advisory role due to liability concerns
- No State Trauma Medical Director (separate from State EMS Medical Director)
- Legislature should expand RPAB role from advisory to authoritative under direction of EMS Board and State Medical Director
- Legislature should extend liability protection to RPABs and provide limited administrative immunity for medical directors
- OEMS should redefine EMS regions to align with Homeland Security regions
- Expand RPAB mission from trauma-only to all time-critical diagnoses
- Develop and require medical director certification with statewide database for compliance
- Require verification of medical director registration for all EMS agencies
- Appoint a State Trauma Medical Director (at least 0.25 FTE)
3I. Communications and Infrastructure
(a) Direct quotes:Dispatch centers in Ohio vary from sophisticated to minimally staffed in rural areas. There are neither Emergency Medical Dispatch Center standards nor standards for personnel who routinely dispatch emergency medical services." (Communications, p.31)(b) Data points:
- Enhanced wireline 9-1-1 in 88 counties (statewide)
- Enhanced wireless 9-1-1: Phase II (number + location) in 78 counties; Phase I (number only) in 4 counties
- 9-1-1 funding legislation due to sunset December 31, 2012
- Multi-Agency Radio Communications System (MARCS) — 800 MHz statewide system used by state agencies, sheriffs, county emergency management, many EMS providers, hospitals, health departments
- Transportable Communications System (TCS) available for UHF/VHF patching and 800 MHz redundancy
- County-by-county communications capability assessment completed 2005
- State Board of Education offers 40-hour emergency service telecommunicator course at vocational centers — offered 8 times/year, tuition covered for EMS employees but "very little funding has actually been realized"
- No clear authority for EMD training or requirements
- No EMD center standards or dispatcher certification standards
- Governor's task force oversees State Interoperability Executive Committee (SIEC)
- EMS Board should seek authority for dispatch center and emergency medical dispatcher certification standards
- Create a dispatch subcommittee for medical priority dispatching standards
- Encourage standardized EMD training supported by wireless 9-1-1 funds
- Conduct regular assessments for ambulances, hospitals, and dispatch centers to ensure interoperability
- Create central dispatch center for air medical services with flight-following and resource tracking
3J. Preparedness
(a) Direct quotes:The lack of authority to regulate EMS agencies inhibits the OEMS's ability to adequately identify and track resources, thus being a barrier in terms of planning for mass casualty events." (Preparedness, p.46)(b) Data points:
- ORC requires EMS Board to provide liaison to state EOC during Governor-declared disasters
- EMS Board required to establish statewide EMS plan and disaster regulation plan consistent with State EOP
- OEMS Homeland Security Coordinator provides staff support
- OEMS, Ohio EMA, and Ohio Homeland Security are all within the Department of Public Safety
- CHEMPACK deployment completed with Ohio Department of Health
- Regional equipment caches deployed; training capacity expansion supported
- H1N1 response: EMT-I and Paramedic personnel authorized to perform immunizations under physician direction (2009)
- Ohio Fire Service Emergency Response System (ERS) adopted as Ohio's statewide plan — database of typed resources, activated through Ohio Central Dispatch Facility
- ERS predominantly fire-service centered; non-fire agencies may choose to participate
- MARCS radio funding authorized by EMS Board for EMS agencies
- Require statewide patient tracking system for all ambulances during MCI/mass casualty incidents
- Develop comprehensive database of EMS resources for MCI use
- Work with Ohio Department of Health on hospital preparedness planning and surge capabilities
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
This is a reassessment of the 2001 reassessment (the original assessment preceded 2001; the Introduction references 2001 as the prior reassessment, p.9).
The report does not include a systematic section-by-section accounting of prior recommendations. Key progress documented:
Accomplished since 2001:- Mandated statewide trauma system established (legislation passed July 2000 — just before prior reassessment)
- 45 hospitals voluntarily verified as trauma centers through ACS
- Statewide trauma triage protocols developed and implemented
- EMS Board Strategic Planning Committee established with SWOT analysis completed
- "A Framework for Improving Ohio's Trauma System" approved (October 2010)
- Trauma rehabilitation registry established (2005 — described as first in nation)
- EMSIRS transitioning to NEMSIS V2 compliance
- Wireless 9-1-1 coverage nearly statewide (78 of 88 counties at Phase II)
- MARCS 800 MHz interoperability system implemented
- EMSC performance measures focused activities
- CAAHEP accreditation required for paramedic programs by 2018
- EMS integrated into homeland security and disaster preparedness
- Bifurcated regulatory system (OEMS vs. OMTB) remains
- No comprehensive statewide EMS plan completed
- No state designation authority over trauma centers
- Funding instability (seatbelt fines declining)
- Data underutilized for system-level QI
- NEMSIS submission blocked by privacy law concerns
- No formal EMS workforce needs assessment
- No EMD standards or dispatcher certification
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall characterization:Despite substantial progress, the job of building Ohio's EMS system remains far from done." (Introduction, p.8)
The next steps in Ohio's EMS system development include a focus on the fundamentals. Authorities at state, regional and local levels must be clarified. A reliable level and source of funding needs to be secured. Structural differences between the regulation of varying forms of EMS agencies must be eliminated." (Introduction, p.8)
Ohio's EMS system meets key elements of each NHTSA standard. With some careful planning, cooperation, and commitment, there is good reason to believe the State can make substantial progress towards becoming a national example of excellence." (Introduction, p.9)
While the Division and the Board have significant responsibilities and appear to be doing excellent work in many areas of EMS and trauma care, they are lacking some of the fundamental capabilities that would enable them to meet the NHTSA standard." (Regulation and Policy, p.14)Structural barriers identified:
- Bifurcated regulatory system (OEMS and OMTB) — described as "an anomaly"
- 70% of ambulance services (fire-based) not state regulated
- "Home rule" politics pervaded many presentations — recognized as barrier to enforcement
- Dual reporting structure for Executive Director (EMS Board Chair and Director of Public Safety)
- Ohio privacy law preventing NEMSIS submission
- No state designation/de-designation authority for trauma centers
- Liability concerns preventing RPABs from serving as regional medical direction boards
The report references the 2006 IOM Report on the Future of Emergency Care in the Background section, framing EMS within "a comprehensive and integrated health management system, with regional accountable systems of care." No explicit transportation-framework language is used for EMS.
Federal funding mechanisms:- Highway safety funds referenced as the original funding mechanism for the TAT program (Background)
- Section 408 grant funding ($350,000) from Ohio Office of Traffic Safety for trauma registry upgrade
- EMSC federal funding referenced (consistently since 1987)
- Traffic Safety Office funded the NHTSA assessment
- No Section 402 funds specifically named
- Over 42,000 certified EMS personnel with strong growth at paramedic level
- 45 voluntarily verified trauma centers — "quite impressive" without financial incentives
- State EMS Medical Director (Dr. Carol Cunningham) — nationally recognized, designated in law
- EMS training and education capabilities — "strong capabilities"
- MARCS 800 MHz interoperable communications system
- Near-complete wireless 9-1-1 implementation
- EMSIRS and Ohio Trauma Registry as legislatively created data systems
- Trauma rehabilitation registry — first in the nation
- EMS integration into homeland security and disaster preparedness
- Ohio Injury Prevention Partnership (OIPP)
- EMS Board Strategic Planning Committee with SWOT analysis
- EMSC program continuously funded since 1987
- Bifurcated regulatory system / inability to account for all EMS resources statewide
- Declining seatbelt fine revenue threatening financial viability
- "Home rule" barriers to enforcement
- Data underutilization — rich data not transformed into policy guidance
- Legal barriers to NEMSIS submission
- Exclusive (not inclusive) trauma system
- No State Trauma Medical Director
- No EMD standards or dispatcher certification
- No formal workforce needs assessment
- CAAHEP accreditation cost barrier for paramedic programs
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
Bifurcated Regulatory System as Central Finding
The existence of two separate regulatory boards — the State Board of EMS and the Ohio Medical Transportation Board — is the dominant structural finding. The TAT called it "an anomaly" and repeatedly recommended consolidation. The consequence is that OEMS cannot determine the total number of EMS organizations or vehicles in the state and 70% of ambulance services (fire-based) are not state regulated.
"Home Rule" as Structural Barrier
The report documents "home rule" as a pervasive cultural/political barrier. The TAT noted that "similar 'home rule' excuses pervaded many presentations to the TAT when there appeared to be a common understanding about why OEMS is unable to enforce requirements that are clearly the right thing for EMS patients." This is an unusually direct characterization of a political dynamic.
Seatbelt Paradox
Ohio's primary EMS funding source — seatbelt violation fines — is declining because seatbelt compliance is increasing. The TAT characterized this as "a good thing" and "a bad thing" simultaneously. The funding mechanism's structure means that the success of a public safety initiative is undermining the financial viability of another public safety infrastructure. The driving abstract fee supplement faces a legal challenge. This is an unusually explicit documentation of a funding paradox.
Ohio as EMS Personnel Exporter
The report documents Ohio as a net exporter of trained EMS personnel. The Tennessee example — approximately 75% of 150 new paramedics hired by one department came from Ohio — is striking. Rural volunteer agencies report losing personnel they trained (using grant funds) to urban areas. This brain-drain dynamic is documented from both ends.
Trauma Rehabilitation Registry — First in the Nation
Ohio established a trauma rehabilitation registry as a module of the Ohio Trauma Registry in 2005, described as "the first of its kind in the nation." However, as of the reassessment, the data had not been linked to acute care data for meaningful analysis, representing a first-in-nation capability that remained unfulfilled.
45 Voluntary Trauma Centers Without Financial Incentives
The TAT noted it was "quite impressive" that 45 hospitals voluntarily underwent ACS verification (every three years) and participated in the trauma system without financial incentives. This is a relatively high number for a voluntary system with no state designation authority and no uncompensated care fund.
Ambulance Staffing Rollback
A 2008 legislative change reduced minimum ambulance staffing from 2 EMTs to 1 First Responder and 1 EMT. This was described as "controversial" and paradoxically created a burden for rural providers who previously staged minimum staffing with one EMT arriving at the scene. The TAT recommended restoring the two-EMT minimum.
OEMS as Dual EMS/Fire Agency
The OEMS serves as lead agency for both EMS and fire service training/certification — over 42,000 firefighters and 10,000 fire safety inspectors in addition to 42,000 EMS personnel. This dual mandate is relatively unusual and means the division handles approximately 84,000+ certified personnel across both disciplines. Until recently, fire certificates were issued without expiration dates.
Air Medical System Without Oversight
15 air ambulance services with 57 helicopters operate with no certificate of need, no central dispatch, no standardized activation guidelines, and no accreditation requirement such as CAMTS. This is documented without a parallel finding in other assessed states of this scale.Attorney General Barrier to Data Use
The report documents that the OEMS needs to work with the Ohio Attorney General to be authorized to publish statewide aggregate trauma and EMS data and submit to national databases. The legal barrier is not just to patient-level data but apparently to aggregate data publication, which is an unusual restriction.
Analysis produced using standardized NHTSA State EMS Assessment extraction framework. All quotes are from the Ohio 2011 Reassessment report. No editorial synthesis applied.
Oklahoma
Full Analysis
Oklahoma 2009 NHTSA EMS Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Oklahoma
- Report type: Reassessment
- Date of site visit: November 17–19, 2009
- Year of publication: 2009
- Prior assessment year: 1992
- TAT members:
- Steven Blessing, MA (Director, Delaware Office of Emergency Medical Services; President, NASEMSO)
- W. Dan Manz (Director, Emergency Medical Services Division, Vermont Department of Health)
- Susan D. McHenry (EMS Specialist, NHTSA — served as NHTSA facilitator)
- Curtis C. Sandy, MD, FACEP (EMS Medical Director, Rocky Mountain Emergency Physicians, Portneuf Medical Center, Pocatello, ID)
- Jolene R. Whitney, MPA (Deputy Director, Utah Bureau of Emergency Medical Services & Preparedness)
- NHTSA facilitator: Susan D. McHenry, EMS Specialist, NHTSA
- Number of presenters/briefings: Over 20 presenters from the State of Oklahoma
- Requesting agency: Oklahoma State Department of Health, Emergency Systems
SECTION 2: STATE CONTEXT
- Population (as cited in report): Over 3.5 million residents (Introduction). Separately, 3.6 million is cited in the Facilities section.
- Geographic characteristics: Described as "diverse and vast." The major urban corridor extends from Lawton to Tulsa. Three major population centers: Oklahoma City, Lawton, and Tulsa. Approximately 2.5 million people live within 50 miles of these three cities. The remaining 1 million reside in rural and "often frontier territory" (Facilities). The state has 8 recognized EMS regions.
- Number of counties/jurisdictions: Not explicitly stated as a total count. The report references counties in the context of ambulance coverage responsibility.
- EMS system overview:
- Governance structure: 8 EMS/trauma regions, each with a Regional Trauma Advisory Board (RTAB). Advisory councils include OERSDAC (EMS) and OTSIDAC (Trauma). A Medical Direction Subcommittee meets quarterly. A State EMS Medical Director exists.
- Number of agencies/providers: 195 licensed EMS providers: 160 ground ambulance services, 17 air ambulance bases, 18 specialty care providers (Transportation). Over 7,000 EMTs licensed at three levels: EMT (4,400), EMT-Intermediate (750), Paramedic (2,000), plus over 1,000 registered EMRs (Human Resources). 132 acute care hospitals (Facilities). Approximately 160 dispatch centers (Communications).
- Notable demographic or socioeconomic factors cited: Economy showing sustained growth even during the 2009 recession (Introduction). Migration toward the urban corridor from rural areas. Agriculture, energy, aviation, biotechnology, and telecommunications as economic sectors. The 1995 Murrah Federal Building bombing is referenced as a formative event (Introduction). Tobacco tax funding creating substantial trauma care resources.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:The Oklahoma Emergency Response System Development Act (the Act) requires comprehensive EMS system planning and a state EMS plan. Oklahoma has not developed a comprehensive state plan to date" (Regulation and Policy, Status)
Oklahoma lacks a statewide EMS plan for the identification and utilization of EMS resources." (Resource Management, Status)
The State does not have a comprehensive EMS plan with a transportation component" (Transportation, Status)(b) Specific data points: The enabling statute requires a plan, but none has been developed. The absence is cited across at least 3 sections. (c) Report characterization: The TAT notes this is a statutory non-compliance issue — the law requires a plan that has not been produced. The absence is linked to resource maldistribution, particularly in air medical coverage, communications, transportation, medical direction, and dispatch. (d) Priority recommendation:
Emergency Systems, in conjunction with stakeholders, should develop a statewide EMS plan that specifically addresses resource management, particularly in the areas of EMS transport, dispatch, airmedical resources, and medical oversight.
3B. Funding and Financial Sustainability
(a) Direct quotes:Total annual funding is approximately $25 million: $22 million is distributed to providers of trauma care services, including $1.4 million to EMS, and $2.4 million is retained by the Department to fund system management and oversight." (Regulation and Policy, Status)
Any collections over those amounts, up to $2.5 million, are accrued to the Oklahoma Emergency Response Systems Stabilization and Improvement Revolving Fund (OERSSIRF). This is the first year for OERSSIRF, and a little over $1.2 million is expected to be distributed." (Regulation and Policy, Status)
Funding for the trauma system now comes from a tax on tobacco and from traffic violations. The funds distributed are approximately 20 million dollars a year. The majority of the money is spent on hospital costs of the seriously injured patients." (Trauma Systems, Status)
Tobacco funds have created a substantial financial resource to compensate the costs of providing trauma care." (Introduction)(b) Specific data points:
- Total annual funding: approximately $25 million (Regulation and Policy)
- Distributed to trauma care providers: $22 million, including $1.4 million to EMS (Regulation and Policy)
- Retained by Department for system management/oversight: $2.4 million (Regulation and Policy)
- OERSSIRF (new revolving fund): up to $2.5 million cap; approximately $1.2 million expected first year (Regulation and Policy)
- Trauma fund from tobacco tax and traffic violations: approximately $20 million/year (Trauma Systems)
- OKEMSIS software purchased with Oklahoma Highway Safety Office grant (Regulation and Policy)
- "408" grants from OHSO funded OKEMSIS (Resource Management)
- Some state general fund money dedicated to regulatory functions (Regulation and Policy)
The Department should realign the distribution of money from the Trauma Fund to support EMS system improvements and pay for readiness costs rather than primarily subsidizing uncompensated or under compensated trauma care.
The Department should explore opportunities and collaborate with additional federal programs that provide funding for EMS activities such as the Office of Rural Health and The Oklahoma Highway Safety Office (402 funds).
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:The State has identified significant challenges in recruitment and retention of EMTs and providing sufficient training programs with effective local and regional support. The issues of assuring the availability of adequately trained and appropriately licensed EMS personnel to support the EMS system are reportedly most acute in the rural parts of the state." (Human Resources, Status)
There have been a worrisome number of failures of rural ambulance services." (Introduction)
There are areas in the state where primary ambulance coverage is described as 'tenuous', and where the provider agency ability to remain in operation is in question." (Resource Management, Status)
Ambulance services, especially in rural Oklahoma, have struggled to exist. Some communities have been orphaned with no ambulance transport readily available." (Transportation, Status)
Hospitals in rural and frontier areas of the state often experience shortages of prehospital personnel and physicians." (Facilities, Status)(b) Specific data points:
- Over 7,000 licensed EMTs: EMT (4,400), EMT-I (750), Paramedic (2,000) (Human Resources)
- Over 1,000 registered EMRs (Human Resources)
- 195 licensed EMS providers total (Transportation)
- EMR with EVO training is the minimum allowable emergency vehicle operator; Basic EMT is minimum attendant (Transportation)
- No formal personnel needs assessment has been conducted (Human Resources)
Emergency Systems should facilitate a human resources needs assessment as called for in the OERSSIRF legislation
The Oklahoma legislature should establish in statute the responsibility of every county to assure primary and backup ambulance coverage.
The State should ensure through legislation, that there are no orphaned areas in the state without sufficient ambulance service coverage.
3D. Essential Service Designation
(a) Direct quotes:The Oklahoma legislature should establish in statute the responsibility of every county to assure primary and backup ambulance coverage." (Regulation and Policy, Recommendations)
The State should ensure through legislation, that there are no orphaned areas in the state without sufficient ambulance service coverage." (Transportation, Recommendations)
communities that have been left orphaned by failed EMS providers, have created a burden on neighboring communities and their licensed EMS providers to assume the fiscal responsibility for the costs associated with the readiness and provision of emergency medical services to the orphaned community." (Transportation, Status)(b) Specific data points: The report does not use the phrase "essential service." However, the concept of "orphaned" communities without ambulance coverage is documented as an active problem, and the TAT recommends legislative county-level responsibility for EMS coverage. (c) Report characterization: Oklahoma's "closest ambulance" rule requires the nearest ambulance to respond regardless of jurisdictional boundaries, but this creates unfunded burden-shifting when a service fails. The TAT recommends statutory county responsibility — functionally equivalent to essential service designation. (d) Priority recommendation: Two separate recommendations address this: county responsibility for primary and backup coverage (Regulation and Policy) and legislative prohibition on "orphaned areas" (Transportation).
3E. Regulatory Fragmentation
(a) Direct quotes:As a result, there are areas of the state where certain resources are available in overabundance and also areas of the state where those same resources are limited or unavailable. This is particularly noticeable in the areas of air medical coverage, communication, transportation, medical direction, and dispatch." (Resource Management, Status)
The eight Trauma regions were initially established based on the original Homeland Security regions. This approach did not take into account the provision of regionalized emergency health care based upon routine transfer or transport of patients." (Transportation, Status)(b) Specific data points:
- 8 EMS/trauma regions (not aligned with patient flow patterns) (Transportation)
- 195 licensed EMS providers (Transportation)
- 160 dispatch centers, of which only 20% dispatch EMS ambulance resources (Communications)
- 3 Native American hospitals not participating in the state program (Facilities)
- Non-transporting EMR agencies are not licensed (Transportation)
The Department should conduct a study to determine the feasibility of realignment and reduction in the number of EMS/trauma regions to more closely fit routine referral patterns between EMS and hospitals.
3F. Data and Evaluation Systems
(a) Direct quotes:Other states would be envious of Oklahoma's EMS and trauma information system." (Introduction)
Oklahoma's trauma registry has been described as 'one of the best in the country' by a recent NHTSA Traffic Records Assessment." (Evaluation, Status)
Over 400,000 responses per year are collected by the Oklahoma EMS Information System (OKEMSIS), which was implemented this year using ImageTrend, a commercial web-based statewide data system compatible with the National EMS Information System (NEMSIS)." (Regulation and Policy, Status)
Emergency Systems has dedicated 3 epidemiologists to manage the data systems and to develop OKEMSIS into a research-quality database." (Regulation and Policy, Status)
Other than the trauma CQI process, no formal process yet exists to evaluate the effectiveness of prehospital treatment protocols, destination protocols and 9-1-1 protocols." (Evaluation, Status)(b) Specific data points:
- OKEMSIS: NEMSIS-compliant, ImageTrend web-based, collecting over 400,000 responses per year (Regulation and Policy)
- 3 epidemiologists dedicated to data systems (Regulation and Policy)
- Oklahoma Trauma Registry: described as "research-quality" and "one of the best in the country" (Regulation and Policy, Evaluation)
- Quarterly NEMSIS uploads already occurring (Regulation and Policy)
- Trauma CQI exists at RTAB level; no formal prehospital protocol evaluation exists (Evaluation)
- Trauma peer-review data is protected from discoverability; EMS data is not (Evaluation)
- No unique patient identifier for tracking through prehospital to in-hospital care (Evaluation)
The Oklahoma legislature should provide protection from discoverability for all peer-reviewed EMS data.
Emergency Systems should utilize the trauma registry model for OKEMSIS to facilitate CQI, system improvements, and policy/legislative development.
3G. Trauma System Status
(a) Direct quotes:Oklahoma has a well developed inclusive trauma system made up of multiple levels of trauma centers Level I-IV distributed throughout the state. The State mandates all hospitals participate in the trauma program." (Trauma Systems, Status)
Approximately 3700 trauma patients per year are seen by the level I and II's." (Trauma Systems, Status)
The data is currently being used for research papers related to trauma care. Oklahoma's trauma registry is compliant with the ACS national trauma data standard." (Trauma Systems, Status)(b) Specific data points:
- 1 Level I trauma center (ACS verified, Oklahoma City) (Facilities, Trauma)
- 2 Level II trauma centers (one ACS verified) (Facilities)
- 25 Level III trauma centers (Facilities)
- 80 Level IV trauma centers (Facilities)
- All hospitals required to participate by state law (Trauma)
- 8 Regional Trauma Advisory Boards meeting bimonthly (Trauma)
- Medical Audit Committee of 9 physicians meeting bimonthly (Trauma)
- TReC communication system in Tulsa and Oklahoma City for patient routing (Trauma)
- Trauma fund: approximately $20 million/year from tobacco tax and traffic violations (Trauma)
- 3,700 trauma patients/year at Level I and II centers (Trauma)
- RTTDC and ATLS courses provided by Level I/II centers to rural areas (Trauma)
- RTABs have legal protection for QA activities (Trauma)
The State should require that all level II trauma centers be ACS verified.
The State should arrange a trauma system consultation by the American College of Surgeons as a means of identifying opportunities for improvements.
Emergency Systems should develop a trauma system plan based on national standards.
3H. Medical Direction
(a) Direct quotes:Oklahoma benefits from the services of a State EMS Medical Director who is involved with statewide EMS planning" (Medical Direction, Status)
The quality and intensity of medical direction greatly varies across the state with most rural agency medical directors having minimal education or involvement." (Medical Direction, Status)
Many of the dedicated physicians who provide the medical oversight for the local delivery of EMS do not see themselves as part of a larger coordinated system of care." (Introduction)
here is no requirement or standards for on-line medical direction." (Medical Direction, Status)(b) Specific data points:
- Oklahoma has a State EMS Medical Director (Medical Direction) — the first of the five states analyzed to have this position filled
- A Medical Direction Subcommittee meets quarterly (Regulation and Policy)
- Medical oversight required for any care above EMR level (Medical Direction)
- No standards for on-line medical control (Medical Direction)
- No mandatory training/certification for agency medical directors (Medical Direction)
- No statutory liability protection for off-line medical directors (Medical Direction, Regulation and Policy)
- No medical oversight of EMR agencies/personnel or EMD/dispatch (Medical Direction)
The State should clearly delineate in statute the responsibility and authority of the State EMS Medical Director.
Emergency Systems should develop a mandatory training and certification program for agency medical directors.
Emergency Systems should develop a regionalized medical director program.
The Oklahoma Legislature should provide statutory liability protection for off-line medical directors and clinicians providing on-line medical control.
3I. Communications and Infrastructure
(a) Direct quotes:A substantial number of Oklahoma citizens cannot access emergency medical care via enhanced 9-1-1." (Introduction)
There are approximately 160 dispatch centers. Of those centers, 20% dispatch EMS ambulance resources." (Communications, Status)
There are still rural areas where 9-1-1 has not been implemented." (Communications, Status)
The 1977 'Hospital Emergency Access Radio' (HEAR) system is currently the only statewide interoperable EMS communications system." (Communications, Status)
The current system is a patchwork of frequencies and ambulances often require several radios to ensure they can communicate with all the providers in their service area." (Communications, Status)
Other pervasive issues regarding the communications system include: No pre-arrival instructions; Wrong addresses; Calls are dropped; Lines are busy and calls are forgotten" (Communications, Status)(b) Specific data points:
- Approximately 160 dispatch centers (Communications)
- Only 20% dispatch EMS ambulance resources (Communications)
- Fewer than 20 agencies provide EMD training and certification (Communications)
- Rural areas still without 9-1-1 (Communications)
- E-9-1-1 not achieved statewide (Communications)
- HEAR system (1977) is the only statewide interoperable EMS communications (Communications)
- 800 MHz system is costly and cannot cover entire state due to topography (Communications)
- EMSA (Tulsa/Oklahoma City) handles approximately 150,000 calls per year with trained, certified dispatchers (Communications)
The Department should establish minimum standards for emergency medical dispatch centers including priority medical dispatch and pre-arrival instructions.
The Department in collaboration with the Council of Governments should establish regionalized dispatch centers based on the TReC model.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (Reassessment)
The report measures progress since the 1992 assessment. No formal numbered tracking is provided.
Overall characterization of progress since 1992:There is much pride in what has been accomplished." (Introduction)
The TAT's tone suggests substantial progress since 1992, particularly in trauma system development, data systems, and the legislative/regulatory framework.
Documented as completed or substantially improved:- Comprehensive enabling legislation for EMS and trauma (Regulation and Policy)
- Inclusive trauma system with Level I-IV centers, mandatory hospital participation, RTABs, and dedicated funding (Trauma Systems)
- Research-quality trauma registry — "one of the best in the country" (Evaluation)
- OKEMSIS implemented (NEMSIS-compliant, 400,000+ responses/year) (Regulation and Policy)
- 3 epidemiologists dedicated to data systems (Regulation and Policy)
- State EMS Medical Director position filled (Medical Direction)
- Medical Direction Subcommittee established (Regulation and Policy)
- OERSSIRF revolving fund created (Regulation and Policy)
- TReC patient routing system operational (Trauma Systems, Transportation)
- EMResource system for hospital status monitoring (Resource Management)
- Specialty hospital classification system (8 categories including trauma, cardiac, stroke, pediatric) (Resource Management)
- EMS education aligned with national standards (Human Resources)
- Preparedness infrastructure including REMSS, NIMS, and EMAC participation (Preparedness)
- No statewide EMS plan (required by statute but not developed) (Regulation and Policy)
- Rural ambulance service failures and "orphaned" communities (Introduction, Transportation)
- No statewide E-9-1-1 (Communications)
- 1977 HEAR system as only statewide interoperable EMS communications (Communications)
- No mandatory medical director training/certification (Medical Direction)
- No on-line medical control standards (Medical Direction)
- No formal workforce needs assessment (Human Resources)
- EMS peer-review data not protected from discoverability (Evaluation)
- No statewide trauma system plan (Trauma Systems)
- No county-level statutory responsibility for EMS coverage (Regulation and Policy)
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization:This is the most positive reassessment of the five analyzed. The TAT's tone is congratulatory while identifying specific areas for improvement:
There is much pride in what has been accomplished. Other states would be envious of Oklahoma's EMS and trauma information system." (Introduction)
While there is plenty of work remaining to be done in the area of regulation and policy, Oklahoma should be congratulated for establishing an excellent base that will serve the State well as it moves ahead in refining a maturing EMS system." (Regulation and Policy, Status)
Oklahomans deserve nothing less than world class emergency medical care. With the foundation that has been built by the dedication and expertise of many wise leaders and a continuation of cooperative efforts, that vision is entirely possible." (Introduction)
The concerns are framed as refining a maturing system rather than addressing foundational failures:
he spectacular Oklahoma sunsets are illuminating some concerning clouds." (Introduction)Structural barriers identified:
- No statewide EMS plan despite statutory requirement (Regulation and Policy)
- Rural ambulance service failures creating "orphaned" communities (Transportation)
- Trauma fund distribution heavily weighted toward hospital uncompensated care rather than EMS system development (Regulation and Policy)
- No county-level responsibility for EMS coverage (Regulation and Policy, Transportation)
- 1977 HEAR system as only statewide communications infrastructure (Communications)
- Regions aligned with Homeland Security boundaries rather than patient flow (Transportation)
- Variable medical direction quality in rural areas (Medical Direction)
- Private AMR contracts potentially removing resources from state during emergencies (Preparedness)
Like the Nevada 2009 report, this reassessment references the 2006 IOM Report on the Future of Emergency Care and "regional accountable systems of care" in its standards. Oklahoma's system is explicitly moving toward time-sensitive specialty care beyond trauma — with hospital classification in 8 categories including stroke, cardiac, pediatric, and burn. The TReC system and RTABs represent an operational regionalized accountability framework. This report reflects the most advanced integration of the healthcare framework among the five states analyzed.
Federal funding references:Section 402 funds are explicitly named: "The Department should explore opportunities and collaborate with additional federal programs...such as the Office of Rural Health and The Oklahoma Highway Safety Office (402 funds)." OHSO "408" grants funded OKEMSIS. ASPR, DHS, and Public Health Preparedness funds are referenced for preparedness. FLEX funding mentioned for rural trauma education. EMSC funding supports pediatric initiatives.
Greatest strengths (as identified by the TAT):Other states would be envious of Oklahoma's EMS and trauma information system." (Introduction)
Oklahoma's trauma registry has been described as 'one of the best in the country'" (Evaluation)
Inclusive trauma system with all hospitals required to participate, tiered I-IV centers, dedicated $20M+ funding, and regional QA (Trauma Systems)
State EMS Medical Director in place (Medical Direction)
OKEMSIS: NEMSIS-compliant, 400,000+ responses/year, 3 epidemiologists (Regulation and Policy)
TReC patient routing system (Trauma Systems)
Hospital classification in 8 specialty categories (Resource Management)
Sustained economic growth even during recession (Introduction)Most critical challenges (as identified by the TAT):
- Rural ambulance service failures and orphaned communities (Introduction, Transportation)
- No statewide EMS plan despite statutory requirement (Regulation and Policy)
- 1977 HEAR communications infrastructure (Communications)
- Areas without basic 9-1-1 or E-9-1-1 (Communications)
- Trauma fund distribution weighted toward hospital costs vs. EMS system investment (Regulation and Policy)
- Variable rural medical direction quality (Medical Direction)
- No county-level statutory responsibility for EMS coverage (Regulation and Policy)
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. Most mature system among the five states analyzed
Oklahoma is the only state among the five analyzed that has: a filled State EMS Medical Director position, a research-quality trauma registry, a NEMSIS-compliant data system collecting 400,000+ responses/year with 3 dedicated epidemiologists, an inclusive mandatory-participation trauma system with Level I-IV designation, and dedicated annual funding of approximately $25 million. This represents a fundamentally different starting point from Oregon, Kansas, Michigan, or Nevada.
2. The $25 million funding figure and distribution imbalance
Total annual funding of approximately $25 million — with $22 million distributed to trauma care providers (primarily hospital uncompensated care) and only $1.4 million to EMS — is a significant finding. The TAT explicitly recommends realignment to "support EMS system improvements and pay for readiness costs rather than primarily subsidizing uncompensated or under compensated trauma care." This is a resource allocation question rather than a resource scarcity question — a different structural problem than the other four states face.
3. "Orphaned" communities
The concept of "orphaned" communities — areas where ambulance services have failed, leaving no primary coverage — is documented as an active, ongoing problem. The "closest ambulance" rule creates a legal obligation for neighboring services to cover these areas, effectively shifting unfunded costs. The TAT recommends both county-level statutory responsibility and legislative prohibition of orphaned areas.
4. 1977 HEAR system
The 1977 'Hospital Emergency Access Radio' (HEAR) system is currently the only statewide interoperable EMS communications system.
A 32-year-old radio system as the sole statewide communications backbone is a striking finding, particularly in a state that otherwise demonstrates substantial system maturity. The contrast between the data system sophistication and the communications infrastructure age is notable.
5. Dispatch failures documented in detail
The list of pervasive dispatch issues — "No pre-arrival instructions; Wrong addresses; Calls are dropped; Lines are busy and calls are forgotten" — is unusually specific and concrete. Of 160 dispatch centers, only 20% dispatch EMS resources, and fewer than 20 agencies have EMD-trained dispatchers.
6. Air medical regulation concerns
The Department should use the authority provided under O.A.C. 641 310:641-3-38 to monitor air ambulance service utilization and medical benefit. State funding should be denied unless appropriate utilization can be demonstrated according to prospectively approved criteria.
This recommendation — to deny state funding to air services that cannot demonstrate appropriate utilization — is unusually specific and prescriptive for an NHTSA TAT report and suggests concerns about air medical overutilization.
7. "Individual Protocol" rule
Oklahoma allows ALS providers to operate on non-ALS-licensed ambulances under an "individual protocol rule" — a creative mechanism to extend advanced care into rural areas. The TAT recommends increased medical direction oversight for this program but does not recommend its elimination, recognizing its value.
8. Private contractor EMAC concerns
The state must be able to ascertain the extent of these contracts and communicate with vendors on the details in order to ensure adequate EMS coverage in Oklahoma. As it currently stands, the State cannot control all of its EMS resources in event of emergency due to outside agreements.
The finding that private AMR contracts may remove EMS assets from the state during emergencies — without state knowledge or control — is a notable preparedness concern unique to states with significant private EMS providers.
9. Murrah Building bombing legacy
The 1995 Oklahoma City bombing is referenced as a formative event: "Lessons learned have reverberated throughout Oklahoma and the US in the years since." This historical context shapes the state's approach to preparedness in ways not paralleled in the other four states.
10. Trauma fund as model with caveats
Oklahoma's tobacco tax-funded trauma system ($20M+/year) represents the most developed dedicated funding mechanism in the five-state corpus. However, the TAT's recommendation to realign distribution away from hospital uncompensated care toward EMS system investment suggests that even substantial dedicated funding can be captured by institutional interests (hospitals) at the expense of the broader system needs (EMS readiness, workforce development, communications).
Analysis extracted by standardized framework. No editorial synthesis applied. Page references correspond to section headings within the RTF document, as the source file did not contain consistent page numbering.
Oregon
Full Analysis
Oregon 2006 NHTSA EMS Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Oregon
- Report type: Reassessment
- Date of site visit: March 14–16, 2006
- Year of publication: 2006
- Prior assessment year: 1992
- TAT members:
- W. Dan Manz (Director, Vermont EMS Division, Department of Health)
- Kevin McGinnis, MPS, EMT-P (Program Advisor, National Association of State EMS Officials; Maine EMS Trauma System Manager)
- Susan McHenry (EMS Specialist, NHTSA — served as NHTSA facilitator)
- Stuart A. Reynolds, MD, FACS (General Surgeon, Northern Montana Hospital; Chair, Montana EMS Advisory Council)
- Daniel W. Spaite, MD, FACEP (Tenured Professor of Emergency Medicine, University of Arizona College of Medicine)
- NHTSA facilitator: Susan D. McHenry, EMS Specialist, NHTSA
- Number of presenters/briefings: Over 25 presenters from the State of Oregon provided briefings over the first day and a half (p. 5)
- Requesting agency: Oregon Emergency Medical Services and Trauma Systems Section (OEMSTS), in concert with the Oregon Transportation Safety Division (p. 4)
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not documented in this report. The report does not cite Oregon's population figure.
- Geographic characteristics: The report references "frontier, rural, and urban areas" (p. 15), describes Oregon as having "very rural and frontier areas" (p. 17), and notes that "most other regions are predominantly rural" outside the Portland metropolitan area (p. 20). The report references geographic and time constraints dictating triage to nearby facilities (p. 20). No square mileage is cited.
- Number of counties/jurisdictions: Not explicitly stated as a total count. The report references county-level ambulance service area approval, county government authority, and county-level medical direction. The Office of Emergency Management had assisted 22 counties and one region to assess interoperability status (p. 22).
- EMS system overview:
- Governance structure: Regulatory functions are divided among the Office of Public Health, the Board of Medical Examiners, and the Department of Education (p. 12). Counties have authority to approve and inspect ambulance service providers (p. 15).
- Number of agencies/providers: 142 licensed transporting agencies currently operating in Oregon (p. 15). Non-transporting agencies are unregulated (p. 12, 15).
- Notable demographic or socioeconomic factors cited: The report cites that over 5,000 Oregonians die annually from prehospital cardiac arrest or trauma (p. 8). No other demographic or socioeconomic data is cited.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:There is no State EMS Plan although the new EMS Director has taken steps to bring stakeholders together to begin the development of one." (p. 12)
The lack of a statewide EMS plan has prohibited an assessment of needs related to the frontier, rural, and urban areas of the State and by default has created a disparity in available resources with no clear plan to enhance the resources of rural and frontier Oregon." (p. 15)
The Oregon State EMS and Trauma System Section has neither the authority, funding, nor staffing to achieve centralized resource coordination of the state EMS system." (p. 14–15)
In the absence of a State EMS plan, there has been no transportation needs assessment to insure uniform pre-hospital coverage." (p. 18–19)
There is no public information, education and prevention (PIEP) program as part of a state EMS plan." (p. 24)
There is no statewide EMS plan containing a comprehensive EMS communications plan." (p. 22)
No state-wide plan for evaluation of EMS systems exists." (p. 32)(b) Specific data points: No plan exists. The absence of a plan is referenced in at least 7 separate sections of the report (Regulation and Policy, Resource Management, Transportation, Communications, Public Information/Education/Prevention, Evaluation, and Domestic Preparedness). (c) Report characterization: The TAT characterizes the absence of a statewide EMS plan as a fundamental structural failure. The report states it has prevented needs assessment, resource coordination, and quality evaluation. (d) Priority recommendation: Yes. The report recommends (bolded):
The State EMS Director in cooperation with stakeholders should develop and implement a comprehensive state EMS and trauma plan." (p. 15, repeated in substance across multiple sections)
3B. Funding and Financial Sustainability
(a) Direct quotes:The Oregon State EMS and Trauma System Section has neither the authority, funding, nor staffing to achieve centralized resource coordination of the state EMS system." (p. 14–15)
he absence of adequate funding for the State EMS leadership structure has led to dramatic inability to: --Develop and implement a statewide EMS Plan --Revise and implement a statewide Trauma Plan --Provide cogent overall medical direction for prehospital care in the State --Establish and implement standards of care --Provide leadership that enhances the ability of counties and local agencies to identify their needs..." (p. 9)
Experiencing erosion of the already inadequate funding for leadership, planning, and development of the EMS system." (p. 8)
Funding cuts to the Area Health Education Centers (AHECs) have resulted in a pass through of higher course costs to individual students or their sponsoring EMS agencies." (p. 17)
Unfunded trauma care and the cost of reimbursing the members of the trauma call panel continue to be an issue in maintaining a trauma response in some communities." (p. 30)
This seems to be related to the absence of available Medical Directors with sufficient time to devote to these activities. This is directly related to the lack of compensation for medical direction in the vast majority of counties." (p. 27)(b) Specific data points: No specific dollar amounts, budgets, or appropriations are cited anywhere in the report. The report references highway safety funds (Section 402) only in the Background section as the mechanism for the assessment itself (p. 4). (c) Report characterization: Funding is characterized as "inadequate" and "eroding." The TAT frames inadequate funding as a root cause of systemic failure across virtually every component area. (d) Priority recommendation: Yes. Multiple bolded recommendations call for legislative funding, including:
Instituting this authority should also include the necessary funding and staffing to carry out the responsibilities of this mandate." (p. 15)
The Oregon legislature should support the movement...by...assuring an adequate budget to accomplish their mission as the lead agency." (p. 14)
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:There is little hard data on EMS personnel attrition from within the system. Accordingly, there is not a good foundation upon which to build recruitment and retention plans." (p. 17)
There appeared to be widespread anecdotal agreement that it is becoming more difficult to recruit and retain volunteer personnel." (p. 17)
The career fire agencies with higher call volumes and better salary/benefit packages report more success in filling their staffing needs with qualified personnel." (p. 17)
The very rural and frontier areas of the state face challenges in accessing both initial and continuing education." (p. 17)
The associate degree requirement for Paramedics has made that level of ALS less accessible in low volume areas." (p. 17)
The system of training and certifying EMS first responders is fractured." (p. 16)(b) Specific data points: No specific vacancy counts, graduation rates, attrition rates, or total provider counts are cited. The report notes 142 licensed transporting agencies (p. 15) but provides no personnel totals. (c) Report characterization: The TAT describes the workforce situation as displaying "worrisome symptoms" (p. 17). The lack of data on attrition is itself characterized as a problem. Volunteer recruitment difficulties are characterized as anecdotal but widespread. (d) Priority recommendation: Yes (bolded):
The EMS and Trauma System Section should begin to gather data on what is happening to the EMS workforce. A needs assessment should be performed to identify how many personnel are needed at what level and in what locations of the state. The Section should follow up with EMS personnel who leave the system to determine why they left. It should create a system-wide plan with strategies for attracting new people into EMS, set goals for recruitment and retention, and monitor the progress towards these goals." (p. 18)
3D. Essential Service Designation
(a) Direct quotes: Not documented in this report. The phrase "essential service" does not appear in the report. The report does not discuss whether Oregon legally designates EMS as an essential service. (b) Specific data points: None. (c) Report characterization: N/A. (d) Priority recommendation: The report does not recommend essential service designation. However, the report's overall framing positions EMS as critical to public safety:An organized EMS system is essential to both the daily delivery of EMS and trauma care as well as preparedness for disasters and acts of terrorism." (p. 13)
The report's primary structural recommendation is to relocate the EMS office to the Office of Homeland Security and establish it "at a level equivalent to the State Police, Fire Marshal, and Office of Emergency Management" (p. 13), which implicitly argues for elevated institutional status without using the specific "essential service" framework.
3E. Regulatory Fragmentation
(a) Direct quotes:The existing structure of statutes and administrative rules creates confusion and the possibility of conflict between the Office of Public Health, the Board of Medical Examiners and the Department of Education." (p. 12)
distributing EMS duties among these groups is emblematic of fragmentation that is pervasive within the Oregon EMS system." (p. 12)
In addition to traditional EMS lead agency duties being divided between the Office of Public Health and the Board of Medical Examiners, there is a further subdivision of oversight at the County level via the approval for local ambulance service providers." (p. 12)
This division of regulatory functions leads to poor coordination within the system. For example, there is no single accurate list of medical directors." (p. 12)
There are no established goals for all citizens in Oregon to receive any predetermined standards of care or system performance." (p. 12)
There is no provision for regulation of non-transporting EMS agencies including groups that provide ALS." (p. 12)
Many of the EMS administrative rules are outdated and conflicts exist within rules." (p. 12)
Ambulance Service Areas designated at the county level may prevent the appropriate and quick response of ambulances across service area lines that would optimize EMS access and patient transport." (p. 19)
The EMS system in Oregon is not a system." (p. 9)(b) Specific data points:
- At least 3 state-level regulatory entities: Office of Public Health, Board of Medical Examiners, Department of Education (p. 12)
- Additional county-level regulatory authority over ambulance service providers (p. 12)
- 142 licensed transporting agencies, but non-transporting agencies are completely unregulated (p. 12, 15)
The Governor should take steps, within one year, to transfer the EMS and Trauma System Section from its current location within Public Health to the Office of Homeland Security and establish it at a level equivalent to the State Police, Fire Marshal, and Office of Emergency Management." (p. 13)
All EMS related functions currently held by other State agencies should be moved to the newly formed EMS and Trauma System Office during the transition to Homeland Security (e.g., the Board of Medical Examiners and the Department of Education EMS functions)." (p. 13–14)
The legislature should pass a comprehensive legislative revision that establishes the Oregon EMS and Trauma System Office as the lead agency over all facets of EMS and should recognize the Office as the sole centralized resource coordination entity for the State EMS system." (p. 15)
3F. Data and Evaluation Systems
(a) Direct quotes:here remains no statewide data collection system that would allow evaluation of outcomes for the ill and injured of Oregon." (p. 9)
No state-wide plan for evaluation of EMS systems exists." (p. 32)
No evaluation of patient outcome data occurs at the state and only limited evaluation occurs in a small number of agencies." (p. 32)
There is great variation in the way data is collected by local agencies." (p. 33)
linkage to hospital outcomes is non-existent." (p. 33)
There is no linkage of outcome data with EDs, discharge data, law enforcement, crash reports, FARS, etc." (p. 33)
Thus, it is impossible to know whether patients are receiving optimal care." (p. 33)
The affirmation that high quality care is being provided in Oregon was universal by the presenters. However, it was all anecdotal and negative reports from several national assessments were passed off as being inaccurate." (p. 33)
A minimum, uniform prehospital data set exists although it was unclear whether effective dissemination to EMS agencies has occurred." (p. 33)
Apparently, there is no standard EMS incident reporting process statewide." (p. 33)(b) Specific data points: No NEMSIS version is cited. No state data system name is cited. The report references that a minimum uniform data set "exists" but it is unclear whether it has been effectively disseminated or adopted (p. 33). (c) Report characterization: The TAT characterizes data capability as essentially nonexistent at the state level. The report frames the absence of data as making it "impossible to know" whether patients receive optimal care. The TAT notes that claims of high-quality care were "all anecdotal" and that negative national assessments were dismissed as inaccurate by presenters. (d) Priority recommendation: Yes (bolded):
The EMS lead agency should develop a comprehensive plan to implement a statewide EMS evaluation program including provision for funding. This should establish the minimum data set for state-wide use based upon the most current version of NEMSIS (Available on www.NEMSIS.org)." (p. 34)
3G. Trauma System Status
(a) Direct quotes:Following the last assessment, the trauma system continued to grow and mature, based on two Level I facilities in the Portland metropolitan area (with other metropolitan facilities excluded by design) and inclusion of essentially all other hospitals at level II, III, or IV designation." (p. 29)
After this period of growth, the trauma program appeared to reach a plateau from which there has been a steady decline, possibly resulting from the frequent change of EMS Directors." (p. 29)
Initial expectations for hospitals to be designated at their highest level have been relaxed, and four Level II facilities elected to reduce their designation to Level III and some Level III facilities have been required to drop to Level IV status as a result of losing sub-specialists." (p. 29)
Surgical sub-specialty physician participation in trauma care is problematic in many areas of the state." (p. 29)
The uncertainty of the system leadership may also have contributed to the turnover of 23 trauma coordinators and registrars recently." (p. 29–30)
The trauma registry has not been upgraded or modernized and has proven to be difficult for local facilities to use. This has resulted in significant delays in data entry, and precludes the availability of timely, useful data for QA and for evaluating specific trauma care questions." (p. 30)
Staffing of the trauma program has been reduced to three individuals." (p. 30)
he trauma registry based biennial report reflects data that is more than three years old." (p. 30)
There is no statutory provision for a State Trauma Advisory Board (STAB), but in practice, this group exists and is referenced in administrative rule." (p. 12)(b) Specific data points:
- 2 Level I trauma facilities in the Portland metropolitan area (p. 29)
- 4 Level II facilities elected to reduce designation to Level III (p. 29)
- 23 trauma coordinators and registrars turned over recently (p. 29–30)
- Trauma program staffing reduced to 3 individuals (p. 30)
- Biennial trauma report data was more than 3 years old (p. 30)
- The trauma registry was DOS-based (p. 30)
The Oregon legislature should establish statutory authority for the STAB to address state-wide trauma care issues." (p. 31)
The STAB and the EMS lead agency should determine the number of trauma centers at various levels needed to support the volume of trauma patients in Oregon." (p. 31)
3H. Medical Direction
(a) Direct quotes:There is no State EMS Medical Director and no clearly defined role, authority, or responsibility for such a position. No consistent overall medical direction planning is occurring at the State level." (p. 26)
There is enormous variability in the involvement of physicians with EMS personnel in various areas of the State and their relationship to the EMS agencies." (p. 26)
From the state, regional, and county perspective, there is no system of medical direction." (p. 26)
This is directly related to the lack of compensation for medical direction in the vast majority of counties." (p. 27)
Multiple physicians testified that the cost and availability of liability coverage for EMS medical direction is becoming a major issue. Failure to deal with this will lead to a shortage of EMS Medical Directors in Oregon." (p. 27)
There is no EMS Medical Director training occurring in Oregon with the exception of that associated with the Emergency Medicine Residency and EMS Fellowship at the Oregon Health Sciences University." (p. 26)
The use of on-line medical direction and consultation appears to be infrequent, even in the parts of the state where it is logistically feasible." (p. 26)
here is no single accurate list of medical directors." (p. 12)(b) Specific data points: No specific counts of medical directors, no compensation figures, no funding amounts cited. (c) Report characterization: The TAT characterizes the medical direction situation as fundamentally absent at the state level and "exceedingly variable" at the local level. The relationship between medical directors and individual EMTs (rather than agencies) is identified as a structural flaw. (d) Priority recommendation: Yes (bolded):
Legislation and funding should provide for a State EMS Medical Director who reports directly to the State EMS Director. The Medical Director, at a minimum, should meet nationally recognized standards...The position should be at least half-time..." (p. 27)
The Oregon legislature should enact statutes that change the relationships between EMS Medical Directors and EMS personnel." (p. 28) — recommending the relationship shift from individual EMTs to agencies.
The Oregon legislature should enact statutes limiting liability exposure for physicians when functioning as an EMS Medical Director." (p. 28)
3I. Communications and Infrastructure
(a) Direct quotes:A universally reliable EMS communications system does not exist in Oregon." (p. 22)
#x27;Dead spots' still exist where radio and cell phone transmission are eroded or blocked." (p. 22)
There is no single statewide EMS coordinating or tactical frequency." (p. 22)
There is no statewide EMS plan containing a comprehensive EMS communications plan." (p. 22)
There appears to be no quality improvement process for EMS communications or for monitoring the age of equipment." (p. 23)
Enhanced 9-1-1 is reported to exist universally throughout the state." (p. 22) — however, mapping of new addresses left to local agencies, resulting in potentially "inconsistent and poorly shared maps among dispatch and response agencies" (p. 22–23). Cellular E-9-1-1 was "being developed but is not complete" (p. 23).(b) Specific data points:
- Frequency systems in use: VHF, UHF, 700 MHz, 800 MHz, cell phone, and ham (p. 22)
- No count of PSAPs is provided
- All PSAPs reported to have Emergency Medical Dispatch (EMD) programs (p. 23)
- 22 counties and one region had been assisted with interoperability assessments (p. 22)
- A State Interoperability Executive Committee (SIEC) had been established (p. 22)
Once these EMS communications needs are identified, they should be brought to the SIEC process by the lead EMS agency staff and strongly represented among other users' needs." (p. 23)
The state EMS lead agency should evaluate the adequacy of comprehensive plans being developed by the SIEC." (p. 23)
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (Reassessment)
The report explicitly addresses the 1992 assessment and measures progress since that time. However, the report does not provide a formal numbered accounting of prior recommendations with completion status. Instead, the report characterizes progress across each component area narratively.
Overall characterization of progress since 1992:he team was dismayed to find that, not only had the State not moved ahead in the provision of a comprehensive, well-planned statewide EMS system…indeed, there has been dramatic deterioration." (p. 8)
Little has changed since 1992 in meeting the standard for Regulation and Policy." (p. 12)
Since specific recommendations were made in 1992 regarding the absence of meaningful EMS data, it was expected that robust data systems would now be available to evaluate whether the extant EMS system has an impact on patient outcomes. On the contrary, there remains no statewide data collection system that would allow evaluation of outcomes for the ill and injured of Oregon." (p. 9)
As was true at the time of the last assessment, the basic standard seems to have been met" regarding facility categorization for trauma hospitals (p. 20), and "Other than for trauma, there continues to be no formal categorization of facility specialty capabilities" (p. 20).Documented as completed or improved:
- Enhanced 9-1-1 reported to exist universally (p. 22)
- Trauma system grew and matured through the 1990s before declining (p. 29)
- The trauma registry was improved for a period (p. 29)
- The newest Public Health Officer realigned the EMS Section within Public Health (p. 12) — characterized as "just a beginning and does not go far enough"
- No statewide EMS plan (recommended in 1992, still absent in 2006)
- No statewide data collection system (recommended in 1992, still absent in 2006)
- The trauma system has experienced "steady decline" from its post-1992 growth (p. 29)
- EMS leadership experienced a "revolving door" of short-tenured directors (p. 8, 12)
- The EMS office was "lost in the basement of the State bureaucracy" (p. 8)
- Funding eroded further (p. 8)
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization:The Introduction (pp. 8–10) is among the most critical in the NHTSA reassessment corpus. Key language:
he team was dismayed to find that, not only had the State not moved ahead in the provision of a comprehensive, well-planned statewide EMS system…indeed, there has been dramatic deterioration." (p. 8)
The EMS system in Oregon is not a system." (p. 9)
EMS in the Great State of Oregon is now a 'Tale of Two Systems.'" (p. 9)
Even a cursory reading of the recommendations of this report will show that they don't call for modest incremental improvements. They call for immediate, dramatic change." (p. 9)
The lack of EMS leadership from the State has put the citizens of Oregon at risk." (p. 8)
The TAT used three dashes to structure their critique of state-level failure:
--Lost in the basement of the State bureaucracyStructural barriers identified:
--A revolving door for short-tenured State EMS Directors
--Experiencing erosion of the already inadequate funding for leadership, planning, and development of the EMS system." (p. 8)
- Division of regulatory authority across three state agencies plus county government (p. 12)
- Statutory framework limited to ambulance regulation rather than comprehensive EMS system oversight (p. 12)
- Low institutional placement of EMS office within state government hierarchy (p. 8, 12)
- Lack of statutory authority for the STAB (p. 12)
- Medical direction statute tying physician relationships to individual EMTs rather than agencies (p. 26, 28)
- Lack of authority to regulate non-transporting agencies (p. 12)
- County ambulance service area boundaries preventing cross-boundary response (p. 19)
The report operates primarily within the transportation framework. The assessment was requested through the Oregon Transportation Safety Division (p. 4) and funded through NHTSA highway safety funds (p. 4). The primary structural recommendation is to move EMS from Public Health to the Office of Homeland Security (p. 13), which is neither a healthcare nor transportation placement. The report does reference the "1996 EMS Agenda for the Future" (p. 4), which envisions EMS integration into a "comprehensive and integrated health management system," but the recommendations do not operationalize this healthcare vision.
Federal funding references:NHTSA has determined that it can best use its limited resources if its efforts are focused on assisting States with the development of integrated emergency medical services (EMS) programs" (p. 4)
The Background section references "highway safety funds" as supporting the technical evaluation (p. 4). HRSA regional coordinators are mentioned in the Facilities and Domestic Preparedness sections (pp. 20–21, 35). No Section 402 funds are cited by name.
Greatest strengths (as identified by the TAT):key stakeholders within the Oregon EMS system seem very motivated to cooperate and work for improvement. These dedicated professionals within both pre-hospital and hospital disciplines deserve a system structure that can promote their efforts" (p. 13)
At the street level, there is broad anecdotal evidence that the personnel and agencies are working diligently to provide excellent care to the citizens of the State." (p. 9)
Oregon's system of initial training, leading to the certification of EMS personnel at the EMT-Basic (EMT-B), EMT-Intermediate (EMT-I), and EMT-Paramedic (EMT-P) levels appears to be working reasonably well." (p. 16)
EMS in the State of Oregon enjoys a great heritage. 9-1-1 was implemented early in Oregon. One of the earliest statewide trauma systems was developed in Oregon. One of the top medical schools for the training of Emergency Physicians and Trauma Surgeons is in Oregon." (p. 8)Most critical challenges (as identified by the TAT):
- Absence of a statewide EMS plan (cited across all sections)
- Dramatic deterioration since 1992 (p. 8)
- Fragmented regulatory authority (p. 12)
- No statewide data system to evaluate outcomes (p. 9, 32–34)
- No State EMS Medical Director (p. 26)
- Inadequate and eroding funding (p. 8, 14–15)
- Leadership instability — revolving door of EMS Directors (p. 8, 12, 29)
- Declining trauma system (p. 29–30)
- EMS excluded from domestic preparedness activities (p. 35)
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. Severity of deterioration since prior assessment
This reassessment is notable for documenting not merely stagnation but active "dramatic deterioration" since the 1992 assessment. The TAT states:
In 1992, the Technical Assistance Team that reported the Oregon EMS Assessment did so with great anticipation for the future. It looked as if the State had a good EMS and trauma system on the verge of becoming great…possibly even a model for the country. The momentum for this to happen seemed, at that time, to be substantial and the optimism was palpable." (p. 8)
This is contrasted with the 2006 finding of system-wide decline, making this one of the more negative reassessments in the NHTSA corpus.
2. Recommendation to relocate EMS out of Public Health
The TAT's primary structural recommendation — to move the EMS office from Public Health to the Office of Homeland Security — is unusual. The report explicitly proposes establishing EMS "at a level equivalent to the State Police, Fire Marshal, and Office of Emergency Management" (p. 13). This placement recommendation is distinctive and reflects a post-9/11 framing of EMS as a public safety/homeland security function rather than a public health or transportation function.
3. EMS explicitly excluded from preparedness activities
The EMS and Trauma System Section was explicitly excluded from attending meetings on related preparedness activities and grant opportunities." (p. 35)
This finding — that the state EMS office was actively excluded from (rather than merely overlooked in) homeland security preparedness — is striking and indicates an institutional marginalization beyond mere neglect.
4. "Tale of Two Systems" framing
The TAT's characterization of Oregon EMS as a "Tale of Two 'Systems'" (p. 9) — distinguishing between committed local delivery and a non-functional state-level "system" — is a distinctive rhetorical device. The TAT explicitly states: "The EMS system in Oregon is not a system" (p. 9).
5. No statewide data system 14 years after first recommendation
The fact that the 1992 assessment recommended data systems and the 2006 reassessment found no progress on this recommendation is a notable data point regarding the implementation gap between NHTSA recommendations and state action.
6. Trauma system regression
The documentation that 4 Level II trauma centers voluntarily downgraded to Level III and that some Level III centers dropped to Level IV (p. 29), combined with the turnover of 23 trauma coordinators and registrars (p. 30) and the reduction of trauma program staffing to 3 individuals (p. 30), constitutes a documented regression in trauma system capability that is atypical of NHTSA reassessment findings.
7. DOS-based trauma registry
The trauma registry was still DOS-based in 2006 (p. 30), with biennial report data more than 3 years old. The report notes that a replacement web-based system had been proposed (p. 30).
8. Liability coverage for medical directors
Multiple physicians testified that the cost and availability of liability coverage for EMS medical direction is becoming a major issue. Failure to deal with this will lead to a shortage of EMS Medical Directors in Oregon." (p. 27)
The TAT recommended legislative liability protection for EMS medical directors (p. 28), reflecting an emerging concern that would become more prominent in later state assessments nationally.
9. Exemptions from licensing
The report identifies exemptions from licensing and inspection for the "timber industry" and "ambulances 'operated by anyone licensed to attend to patients'" as representing "a loophole to the assurance of quality pre-hospital care" (p. 19). The timber industry exemption is a state-specific anomaly.
10. Tone of the Introduction
The Introduction to this report (pp. 8–10) is unusually direct and emotional for an NHTSA TAT report. The opening hypothetical about predicting an event that would kill 5,000 citizens, and the subsequent statement that the TAT "can absolutely predict" such deaths from cardiac arrest and trauma annually, employs a rhetorical urgency rarely seen in the assessment corpus. The language calling for "immediate, dramatic change" rather than "modest incremental improvements" (p. 9) is notably forceful.
Analysis extracted by standardized framework. No editorial synthesis applied. All page references correspond to the PDF pagination of the source document.
South Dakota
Full Analysis
South Dakota 2002 NHTSA State EMS Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: State of South Dakota
- Report type: Reassessment
- Date of site visit: June 18–20, 2002
- Year of publication: 2002
- Prior assessment year: 1994
- TAT members:
- Mark King — Director, West Virginia Office of EMS; President Elect, NASEMSD; NREMT-P
- Kevin McGinnis, MPS, EMT-P — Director, Regional Ambulance Services, Franklin Memorial Hospital, Maine; Program Advisor, NASEMSD; Former Director, Maine State EMS (1986–1996)
- Susan McHenry — EMS Specialist, NHTSA (NHTSA facilitator); Past President, NASEMSD
- Stuart Reynolds, MD, FACS — General Surgeon, Northern Montana Hospital; Chair, Montana EMS Advisory Council; Past Chairman, Montana Committee on Trauma
- Susan Ruane, MD, FACEP — Emergency Physician, Worcester Medical Center; Instructor, University of Massachusetts Medical School
- NHTSA facilitator: Susan McHenry
- Number of presenters/briefings: Over 22 presenters
- Requesting agency: South Dakota Office of Emergency Medical Services (OEMS), in concert with the South Dakota Governor's Highway Safety Office
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not explicitly stated.
- Geographic characteristics: Described as "a large, rural state" (p. 21). No square mileage cited. The report references "widely divergent localities and cultures" (p. 5), "widely dispersed communities" (p. 21), "remote parts" (p. 5), and "frontier" areas. The TAT notes "great distance between facilities" as a defining characteristic (p. 22).
- Number of counties/jurisdictions: 66 counties implied (38 with E-911, 7 with ANI, 12 with basic 911, 9 with no centralized dispatch). Not explicitly counted but referenced through 911 county data.
- EMS system overview:
- OEMS Director: Bob Graff, State Director
- State EMS Medical Director: None. "South Dakota does not have a State EMS Medical Director" (p. 28).
- Number of agencies/providers: 131 ambulance services operating 258 certified vehicles; 3,257 certified/licensed personnel (2,735 EMT-B, 248 EMT-I/85, 16 EMT-SS, 258 EMT-P); 4 helicopter services, 3 fixed wing ALS services, 7 fixed wing BLS services
- Service sponsorship: Private/Incorporated/Paid: 20; Paid Fire: 3; Volunteer: 97 (74%); Hospital: 3; Indian Health Service: 7; Federal: 1
- Advisory structure: State EMS Advisory Council sunset in 2001 and was not reappointed. A Trauma System Advisory Committee (appointed 1995) evolved into a Trauma Stakeholders Group. An EMSC Advisory Board continues.
- Notable demographic or socioeconomic factors cited: Native American population explicitly referenced as included in educational opportunities (p. 5). Indian Health Service operates 7 ambulance services and 5 IHS hospitals plus 3 VA hospitals are within the state (p. 21–22). The report notes highway mortality rates, suicide rates, and infant/child mortality rates "above the average national rates" with "some of these rates among the highest in the nation" (p. 35). The state has a citizen (part-time) legislature meeting annually.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Planning
(a) Direct quotes:he absence of clear statutory authority for a lead agency consistently and predictably funded, and bureaucratically positioned to plan, implement and coordinate a comprehensive EMS system is evident." (p. 5)
existing EMS legislation is not comprehensive, i.e., it does not address each of the recognized component areas of EMS" (p. 8)
There was no evidence of centralized monitoring and analysis of EMS system resources." (p. 11)
There continues to exist no transportation plan or surveillance mechanism to measure the status of services, vehicles, and other assets of the system." (p. 18)(b) Specific data points: No statewide EMS plan is referenced as existing. No comprehensive enabling legislation. No transportation plan. No education plan. No communications plan. The report references legislative issue papers prepared in anticipation of the 2003 session but no plan document. (c) TAT characterization: The absence of a comprehensive plan and the lack of statutory lead agency authority are identified as the foundational deficits of the system. The TAT frames the Introduction around this finding. (d) Priority recommendation: Yes (bold, p. 8):
Develop comprehensive state EMS enabling legislation which establishes the current Department of Health EMS Program as the State lead agency to: Coordinate all State resources and activities related to EMS; Plan, implement and coordinate a comprehensive EMS system...
3B. Funding and Financial Sustainability
(a) Direct quotes:Crucial to EMS will be financial support and generation of new revenues so that the mission can continue for all citizens of the State of South Dakota." (p. 5)
Ambulance services in low population and call volume areas are hard-pressed to replace ambulance vehicles. Low volume means little patient-derived revenue, and low population means little tax-base potential to support such purchases." (p. 19)
EMS operations on the various Native American reservations were 'challenged' to survive financially and many rural and frontier EMS agencies were experiencing difficulty in replacing aging ambulances due to low call volumes and insufficient tax bases in their communities." (p. 11)
most of the volunteer EMS agencies probably were not billing appropriately for services." (p. 11)(b) Specific data points:
- $1,000,000 one-time legislative appropriation for ambulance service equipment (2001)
- $100,000 for Public Access Defibrillation (2001)
- $22 million statewide digital communications system (Motorola) — being designed and implemented
- OEMS purchased computers for 112 of 130 ambulance services for new data reporting system
- Office of Rural Health funding used for medical direction issues and data system computers
- Federal Trauma System Grant Program funds used as mini-grants
- No dedicated, sustainable EMS funding source documented
- No indication of OEMS annual operating budget
- Most volunteer agencies not billing appropriately
Encourage ambulance services to bill appropriately for services" (p. 12)
Limit distribution of future grant funds to ambulance services that have implemented appropriate billing, use of ambulance district revenue generation, or both." (p. 12)
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:Since the 1994 assessment, it appears that the percentage of volunteer services has dropped from 85% to 74% and the number of personnel certified or licensed has dropped from 3,800 to 3,257." (p. 18)
The Team could not conclude that these figures are indicative of erosion of the volunteer services." (p. 18)
No service has filed a 30 day notice of discontinuation and gone out of existence in at least 20 years according to OEMS testimony." (p. 18)
The statutory 'hardship exemption' is constantly in use by approximately 10% of the services licensed, primarily to get around the two-EMT response requirement." (p. 19)
A January 2002 survey of ambulance services identified the top two concerns as: (1) Training and (2) Recruitment/Retention (p. 10).
(b) Specific data points:- Total certified/licensed personnel: 3,257 (down from 3,800 in 1994)
- EMT-B: 2,735; EMT-I/85: 248; EMT-SS: 16; EMT-P: 258
- Volunteer services: 97 of 131 (74%, down from 85% in 1994)
- ~10% of services using hardship exemption (primarily to avoid two-EMT requirement)
- 150 Instructor/Coordinators statewide
- No service has ceased operations in at least 20 years
- First Responder not a level of licensure in the state
- EMT-SS declining to 16 providers
- 7 CISM teams, volunteer-staffed, no statewide coordination
Establish a statewide education committee... to: Develop a statewide education plan which includes a manpower needs and training program needs surveillance (ongoing assessment) system
Establish 'First Responder' as a level of licensure
Also bold (p. 16):
Transfer all licensure, scope of practice and other EMS personnel oversight responsibilities to OEMS from the Board.
3D. Essential Service Designation
(a) Direct quotes: Not documented in this report. The phrase "essential service" does not appear. (b) Specific data points: N/A (c) TAT characterization: Not addressed. The report focuses on lead agency authority and enabling legislation rather than essential service designation. Ambulance district models are praised as "excellent models of community EMS operations" (p. 11), suggesting a local funding/governance mechanism without the essential service framework. (d) Priority recommendation: N/A — not addressed.3E. Regulatory Fragmentation
(a) Direct quotes:distribution of authority over EMS issues and personnel among Department of Health offices and other state agencies" (p. 5)
segregation of duties and authority between the office of EMS and the Board create several 'disconnects' in terminology, standards and practice." (p. 8)
EMT-Basics are certified, while EMT-Special Skills are licensed; complaint investigation is the duty of the OEMS while the discipline of ALS personnel is the duty of the Board; and scope of practice is driven by curricula, but exceptions can be made for the ALS level by Board action while limitations can be imposed by local medical directors." (p. 8)
There is no lead agency for 9-1-1 center development." (p. 23)
hree different nationally recognized EMD programs are being used within the state, but not all 9-1-1 centers are using EMD." (p. 24)(b) Specific data points:
- 2 primary regulatory entities: OEMS (BLS/ambulance services) and Board of Medical and Osteopathic Examiners (ALS personnel)
- Different terminology: "certification" (BLS) vs. "licensure" (ALS)
- No lead agency for 911 development
- 3 different EMD programs in use statewide without consistency
- 9 counties with no centralized dispatch at all
- EMS Advisory Council: sunset 2001, not reappointed
- Ambulance operation rules unchanged since approximately 1980 (with 1994 revision)
- No interstate compacts with neighboring states
Develop comprehensive state EMS enabling legislation which establishes the current Department of Health EMS Program as the State lead agency
Transfer all licensure, scope of practice and other EMS personnel oversight responsibilities to OEMS from the Board.
Re-establish a State EMS Advisory Council via legislation or executive order with defined subcommittees aligned with the functional components of the EMS system.
3F. Data and Evaluation Systems
(a) Direct quotes:There is no system, at present, which evaluates the treatment of children and adults in the state of South Dakota requiring EMS." (p. 35)
Some larger ambulance services do QA/QI within their service, but this information is used only internally." (p. 35)
The OEMS currently has no plan for the use of QA/QI information." (p. 35)(b) Specific data points:
- New statewide EMS data reporting system installed March 2002
- OEMS purchased computers for 112 of 130 ambulance services
- Data entered locally, non-confidential information downloaded monthly to state
- 4 hospitals using the Cales Trauma Registry (purchased by the state)
- No statewide trauma registry system
- No data linkages (trauma registry, crash records, EMS data)
- No statewide QA/QI program
- No confidentiality/non-discoverability protection for EMS QI
- Highway mortality, suicide, and infant/child mortality rates "above the average national rates" and "some among the highest in the nation" (p. 35)
Develop key items which should be tracked across the state, for example, call type by location, scene times, patient refusals, interfacility transfers, and trauma port of entry
Establish a method of due process and rapid resolution to respond to complaints and allegations of substandard care
Pursue linkage of the trauma registry, Department of Transportation crash records and OEMS data
3G. Trauma System Status
(a) Direct quotes:Although there is not an organized trauma system within the state, there are two American College of Surgeons (ACS) verified level II hospitals and one hospital committed to eventual level III verification." (p. 31)
At the present time there is not enabling legislation for a trauma system, no lead agency, and no system registry. The trauma system program has not been implemented, designation cannot take place and the triage and transfer protocols are not mandated." (p. 32)
There is no system QA, knowledge of injury patterns, nor a registry based systemwide injury prevention program." (p. 32)
estimony indicated a lack of surgical commitment to a trauma system" though "ten of the general surgeons in the state are committed... Support by 20% of the surgeons in the state should be regarded as a positive factor and not an impediment" (p. 32)(b) Specific data points:
- 2 ACS-verified Level II hospitals; 1 committed to Level III
- 7 hospitals with defined trauma teams and basic activation guidelines
- 4 hospitals using the Cales Trauma Registry
- No enabling legislation
- No lead agency for trauma
- No system registry
- No designation authority
- Triage and transfer protocols: developed but not implemented
- Trauma System Advisory Committee appointed 1995, evolved into Trauma Stakeholders Group
- "South Dakota Trauma Systems Project" booklet describes planned system
- Federal Trauma System Grant Program funds used as mini-grants
- ~20% of state's surgeons committed to the system
- Development of Trauma Systems course conducted in Sioux Falls 1996
3H. Medical Direction
(a) Direct quotes:South Dakota does not have a State EMS Medical Director." (p. 28)
Particularly disturbing is the continued lack of a State EMS Medical Director" (p. 5)
89/105 services reported having a physician medical director with other services reporting a physician extender medical director. Only three services reported no medical direction at this time." (p. 28)
here are no clear guidelines addressing what is expected from those who do assume this responsibility." (p. 28)
There is no statewide medical directors committee. There are no statewide ALS protocols, and established BLS protocols are not mandated." (p. 29)
some physicians have expressed concern about their legal risk while serving as medical director of an ambulance service." (p. 29)
One physician testified that involvement in EMS can be an additional burden to those already taxed as the only physician in a county or town." (p. 29)(b) Specific data points:
- No State EMS Medical Director
- 89 of 105 responding services have a physician medical director
- 3 services report no medical direction
- Some services report physician extender medical directors
- No statewide medical directors committee
- No statewide ALS protocols
- BLS protocols not mandated
- Medical directors course offered at 6 sites, averaging ~5 physicians per site (~30 trained)
- No legal liability protection for medical directors
- No contact information for medical directors collected on licensure applications
Establish a statewide EMS Medical Director with a clear description of authority and responsibilities
Develop a system of medical direction for the entire State to include the EMS Medical Director working next to the OEMS Director, assisted by administrative and technical staff as deemed necessary.
Require EMS medical direction for all ambulance services.
Assure availability of on-line medical direction for any level of EMS provider with a problem or question during treatment or transportation.
3I. Communications and Infrastructure
(a) Direct quotes:The State is in the process of installing a statewide digital radio system that will cover all fire, EMS, and law enforcement. Mobile radios and a portable with a vehicular extender will be given to every ambulance in the state. All hospitals will also be equipped with the system." (p. 23)
This $22 million dollar system is being designed and implemented by the state's selected vendor, Motorola." (p. 24)
Nine counties have no centralized dispatch center at all." (p. 23)
an ambulance service cannot converse with a dispatcher (e.g. Lemmon)." (p. 19)(b) Specific data points:
- 38 counties with E-911
- 7 counties with ANI only
- 12 counties with basic 911
- 9 counties with no centralized dispatch
- $22 million statewide digital communications system (Motorola) — under construction
- 41 towers, 27 dispatchers at 3 state dispatch centers, 2 engineers, 8 technicians
- 3 different EMD programs in use without statewide standard
- No lead agency for 911 development
- No statewide EMD requirements
Develop legislation and rules pertaining to OEMS as the lead agency for Emergency Medical Dispatch standards for training, certification, and operations
Select a single EMD program for statewide use and certification
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS (1994 Assessment)
Documented as Completed or Substantially Accomplished:
- Medical directors course developed and offered at 6 sites
- Trauma Advisory Committee in place since October 1995
- EMSC Advisory Board continues
- Ambulance trip reporting data collection continued; new system implemented March 2002
- Cales Trauma Registry purchased; 5 hospitals using it
- New statewide communications system being installed ($22M)
- EMS Advisory Council operated for approximately 4 years (before sunsetting)
- 15-hour First Responder replaced by USDOT 40-hour course
- Bridge course for 1994 EMT-Basic curriculum developed and delivered 12 times
- Instructor/Coordinator program taught annually; 150 I/Cs statewide
- Continuing education pre-approval process established
- $1M legislative appropriation for equipment; $100K for AEDs
- 4 helicopter services now operating (up from fewer)
- Resource centers established for training, CE, and technical assistance
- EVOC course developed and promoted
Documented as Not Completed:
- No State EMS Medical Director — identified in 1994, still absent (p. 5, 28)
- EMS Advisory Council sunset in 2001 — not reappointed (p. 8)
- Triage and transfer protocols — developed but not implemented (p. 17, 21)
- Trauma system — no enabling legislation, no lead agency, no designation authority (p. 32)
- Statewide data evaluation system — data collection begun but no evaluation framework (p. 35)
- Comprehensive EMS legislation — not enacted
- Statewide ALS protocols — none exist (p. 29)
- Statewide education plan — none exists (p. 14)
- Transportation plan — none exists (p. 18)
- Communications plan — none exists (separate from the infrastructure investment)
- Ambulance inspection standards — "out of date and inadequate" since approximately 1980 (p. 18)
- QI confidentiality protection — not enacted
- Interstate compacts — none exist
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall TAT characterization of the EMS system:The Introduction opens with a post-9/11 acknowledgment, then delivers a direct structural diagnosis:
On revisit, however, the absence of clear statutory authority for a lead agency consistently and predictably funded, and bureaucratically positioned to plan, implement and coordinate a comprehensive EMS system is evident. Particularly disturbing is the continued lack of a State EMS Medical Director, the current absence of a State EMS Advisory Council, and distribution of authority over EMS issues and personnel among Department of Health offices and other state agencies." (p. 5)
The TAT also commends specific accomplishments:
The government of South Dakota has clearly supported these efforts in meaningful ways; the State will soon have a state-of-the-art communication system for everyone and a continuing education program which will be a model for other states" (p. 5)
The Team was also impressed that the Native American population has been included in all educational opportunities" (p. 5)Structural barriers identified:
- No statutory lead agency authority
- Divided regulatory authority (OEMS/Board)
- No State EMS Medical Director
- EMS Advisory Council sunset and not reappointed
- No comprehensive enabling legislation
- No QI confidentiality protection
- No statewide plans (EMS, education, transportation, communications)
- Ambulance rules unchanged since approximately 1980
- No interstate compacts
- Citizen (part-time) legislature — limiting legislative session opportunities
The Background section reflects the NHTSA transportation framework. The reassessment standards reference the 1996 EMS Agenda for the Future and "evolution into a comprehensive and integrated health management system" (p. 1).
The body of the report operates in a rural healthcare framework — discussions of hospital capability, physician scarcity, Indian Health Service operations, community health integration, and telemedicine reflect healthcare system challenges rather than transportation-focused concerns.
Federal funding mechanisms referenced:- Highway safety funds — assessment program mechanism
- Federal Trauma System Grant Program — remaining funds used as mini-grants (p. 31)
- EMSC Program funding — supports trauma stakeholders and pediatric activities
- Office of Rural Health funding — used for medical direction and data system computers
- $22 million statewide digital communications system
- Monthly continuing education program via Sioux Valley Hospital/USD Medical Center reaching 113 of 131 services — described as "unique and laudable"
- 150 Instructor/Coordinators statewide
- Mountain Plains Health Consortium — "remarkable and unique resource" serving Native American and other providers
- Avera-McKennan Hospital accredited EMS school
- Excellent urban medical direction models (Sioux Falls, Rapid City, Minnehaha County)
- Ambulance service district model praised as excellent
- OEMS/Board collaborative relationship
- No service has gone out of existence in at least 20 years
- Inclusion of Native American population in educational opportunities
- CISM volunteer network in 7 locations
- No State EMS Medical Director (described as "particularly disturbing")
- No statutory lead agency
- EMS Advisory Council sunset
- Divided regulatory authority with "disconnects"
- No statewide EMS plan, education plan, transportation plan, or trauma system
- Ambulance inspection standards from ~1980
- 10% of services constantly using hardship exemption
- 9 counties with no dispatch center; areas where ambulances cannot communicate with dispatchers
- No statewide QA/QI program; no plan for data use
- Highway mortality, suicide, and infant/child mortality rates among highest in nation
- IHS and rural/frontier agencies struggling financially
- Most volunteer agencies not billing appropriately
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
1. Post-9/11 framing. The Introduction opens: "The importance of Emergency Medical Services has never been so much in the minds of Americans as since the terrorist attacks that occurred September 11, 2001." This is the first post-9/11 assessment in this analysis corpus, and the Weapons of Mass Destruction concern is cited as a basis for pursuing interstate compacts (p. 20).
2. "Particularly disturbing." The TAT uses "particularly disturbing" to describe the continued absence of a State EMS Medical Director (p. 5) — language notably stronger than the typically diplomatic assessment vocabulary. This is the second reassessment finding of a missing state medical director (after its identification in 1994), making it a documented failure to address a priority recommendation across an 8-year cycle.
3. EMS Advisory Council allowed to sunset. The state established an EMS Advisory Council that operated for approximately four years before sunsetting in 2001 and not being reappointed (p. 8). The TAT describes this as a "regrettable sunset" that "leaves a void in the oversight component." This represents the loss of a governance structure that was itself a product of prior assessment recommendations.
4. No service closure in 20+ years. Despite the structural challenges, OEMS testified that no ambulance service has filed a 30-day discontinuation notice and gone out of existence in at least 20 years (p. 18). This finding suggests remarkable resilience in the volunteer system, even as the TAT notes apparent declines in volunteer service percentage and total personnel.
5. Hardship exemption as system pressure indicator. Approximately 10% of licensed services constantly use the statutory "hardship exemption" primarily to circumvent the two-EMT response requirement (p. 19). This quantifies the gap between regulatory standards and operational reality in rural/frontier areas.
6. BLS fixed wing air medical service. South Dakota licenses BLS fixed wing air medical services, which the TAT identifies as misleading: the public believes "they are receiving a medically valuable service for which they should pay when, in fact, there is little if any medical benefit needed or derived en route from this level of care" (p. 18). The TAT recommends repealing this license category.
7. Native American EMS inclusion. The report commends the inclusion of Native American populations in educational opportunities and notes the Mountain Plains Health Consortium as a "remarkable and unique resource" providing training through distance learning to Native American and other providers (p. 14). The IHS operates 7 ambulance services and 5 hospitals within the state. However, IHS operations are described as "challenged to survive financially" (p. 11).
8. Ambulance rules unchanged since ~1980. The rules relating to operation of ambulances "have not been revised since 1994, but appear largely unchanged since 1980" (p. 7). This 22-year regulatory stasis reflects the limited capacity of OEMS to update its own framework.
9. Ambulance district model as best practice. The TAT praises ambulance service districts and regional authority models as "excellent models of community EMS operations" (p. 11) and recommends demonstrating these models to county commissioners. This represents a constructive approach to sustainability in low-population areas — local taxing authority dedicated to EMS.
10. Monthly satellite CE reaching 113 of 131 services. The Sioux Valley Hospital/USD Medical Center monthly two-hour training program reaching 86% of the state's ambulance services is described as "unique and laudable" (p. 14). This program addresses a fundamental rural barrier — travel distance for continuing education — and the TAT characterizes it as "a model for other states."
11. Mortality rates among highest in nation. The report documents that South Dakota's highway mortality, suicide, and infant/child mortality rates are "above the average national rates" with some "among the highest in the nation" (p. 35) — cited alongside the finding that no statewide evaluation system exists to understand or address these outcomes.
Analysis extracted: February 2026. Source document: State of South Dakota, A Reassessment of Emergency Medical Services, NHTSA Technical Assistance Team, June 18–20, 2002.
Texas
Full Analysis
Texas 1990 NHTSA Assessment — Structured Analysis
⚠ DOCUMENT LIMITATION: This analysis is based on a newsletter summary published in the Texas EMS Messenger (March/April 1990), not the official TAT report. The summary contains recommendations only — no Standard or Status narrative sections, no direct quotes from TAT findings, no data points, and no page references. All findings below are inferred from recommendations and contextual framing. This analysis should be treated as preliminary and replaced if the full report is obtained.
SECTION 1: REPORT IDENTIFICATION
- State: State of Texas
- Report type: Assessment (initial)
- Date of site visit: January 16–18, 1990
- Year of publication: 1990
- Prior assessment year: N/A — initial assessment
- Source document: Texas EMS Messenger, March/April 1990 newsletter article titled “Florida, Pennsylvania, Washington D.C., Maine, Mississippi, and Vermont experts review Texas EMS”
- TAT members:
- John L. Chew, Jr. (EMS Program Specialist, NHTSA — facilitator)
- Norm Dinerman, MD, FACEP (Chief, Emergency Services, Eastern Maine Medical Center)
- Frank Ehrlich, MD, FACS, FACEP (Professor of Surgery, Hahnemann University Hospital, Philadelphia)
- Larry S. Jordan (Director, EMS Office, Florida Department of Health and Rehabilitative Services)
- W. Daniel Manz (EMS Director, Vermont Department of Health)
- Michael E. Shumaker (Administrator, Grants/Planning/Evaluation, Division of EMS, Mississippi)
- NHTSA facilitator: John L. Chew, Jr.
- Requesting agency: Not stated in summary; Bureau of Emergency Management referenced as lead agency
- Testimonial participants referenced: Bureau of Emergency Management staff, TEMSAC members, systems directors, medical directors, educators
SECTION 2: STATE CONTEXT
- Population: Not stated in summary (Texas 1990 census: ~17 million)
- Geographic characteristics: Not described in summary
- Lead agency: Bureau of Emergency Management, Texas Department of Health (TDH)
- Bureau described as needing to report “directly to the State Commissioner of Health” — implying it was organizationally subordinate to an intermediate layer
- TEMSAC: Texas EMS Advisory Council referenced as providing testimony
- Pending regulatory package: TDH Rules and Regulations Document 157.1–157.20 before the Texas Board of Health at time of assessment
Notable framing from summary:
“The NHTSA group compared Texas against a standard of excellence, not against any other state”
“These recommendations were termed ‘critical’ by the panel of reviewers”
“many of the recommendations, particularly in the area of trauma, are already Bureau and Texas Department of Health action items”
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
Note: Without Status sections, all findings are inferred from recommendations. Absence of a recommendation does not indicate absence of a gap — only that it was not captured in this summary.
3A. Statewide EMS Planning
Inferred from recommendations:
- Comprehensive EMS rules package pending but not yet adopted (157.1–157.20)
- Bureau’s organizational placement below direct Commissioner reporting suggests limited authority
- Budget request does not reflect “total implementation requirements for all assigned program responsibilities” — implying underfunding and incomplete legislative budget requests
- Board of Health submits the budget request (not the Bureau directly)
Recommendation language:
- Adopt comprehensive rules package
- Establish Bureau as reporting directly to Commissioner of Health
- Require Bureau to develop legislative budget request reflecting full program needs
- Require Board of Health to submit full budget request to legislature
Report characterization (inferred): The Bureau is under-positioned organizationally and under-resourced financially. The pending rules package represents a comprehensive regulatory framework awaiting adoption.
3B. Funding and Financial Sustainability
Inferred from recommendations:
- Medicaid reimbursement rate insufficient relative to actual transport costs
- No funding mechanism for trauma system management
- Undercompensated trauma care identified as a systemic problem
- Suggested funding sources: DWI fines, license plate fees, beer/alcohol tax
Recommendation language:
- Increase Medicaid reimbursement “commensurate with the cost of delivering prehospital and interhospital transportation”
- Develop funding mechanism for trauma system management (citing DWI fines, plate fees, alcohol tax as models)
- Conduct 6-month study to evaluate cost of undercompensated trauma care
- Develop state mechanism for funding undercompensated trauma care
- Evaluate effect of Texas auto insurance laws on undercompensated care
- Require full budget request reflecting all program responsibilities
Report characterization (inferred): Multiple funding gaps across reimbursement, system management, and trauma care. The recommendation for a 6-month undercompensated care cost study suggests the scope of the problem was not yet quantified.
3C. Workforce — Recruitment, Retention, and Staffing
Inferred from recommendations:
- EMT-Basic not yet established as minimum staffing level for prehospital care
- Rural EMS requires “Grandfather” and variance provisions — implying sub-EMT personnel in the system
- No standards/rules for course coordinators and instructors
- No standardized curriculum use statewide
- Training program audits not conducted
- State-developed examinations used rather than national examination service (NREMT)
Recommendation language:
- Adopt basic EMT as minimum staffing component
- Recognize rural EMS needs with grandfather/variance provisions
- Develop standards for course coordinators and instructors
- Implement standardized curriculum statewide
- Audit all EMT training program levels
- Consider national examination service
Report characterization (inferred): Training and certification infrastructure was fragmented with no standardized oversight. The EMT-Basic minimum staffing recommendation — with explicit rural exemptions — suggests sub-EMT providers were delivering patient care in 1990.
3D. Essential Service Designation
Not addressed in summary.
3E. Regulatory Fragmentation
Inferred from recommendations:
- Bureau not positioned at appropriate organizational level (not reporting to Commissioner)
- Comprehensive rules package pending but not adopted
- No rules/regulations defining medical director requirements within EMS statutes
- No standards for EMS provider licensure (rules pending Board approval)
- No regulatory requirements for interhospital ground and air transfers
Report characterization (inferred): Pre-regulatory framework. The pending 157.1–157.20 rules package appears to be the foundational regulatory structure for the system, awaiting Board of Health adoption.
3F. Data and Evaluation Systems
Inferred from recommendations:
- No statewide data collection system
- No minimum data set requirement for prehospital providers
- No confidentiality protection for state-acquired data
- No consistent QA program
- No performance standards
- Ambulance trip reports not consistently delivered to hospitals with patients
- No trauma registry
- Insufficient resources for statewide EMS data management
Recommendation language:
- Develop and implement statewide data collection system
- Mandate minimum data set for all prehospital providers
- Achieve confidentiality protection
- Achieve consistent QA program
- Develop performance standards
- Achieve sufficient resources for data management
- Assure trip report delivery with patient
Report characterization (inferred): Complete absence of systematic data infrastructure — seven distinct data/evaluation recommendations suggest this was among the most deficient areas.
3G. Trauma System Status
Inferred from recommendations:
“Policy makers must remember at all times that a good trauma system is only a small component of the EMS system in which it exists. If the EMS system is inadequate in any component so then will be the resultant trauma system.”
This is the only direct TAT quote preserved in the summary — and it is a fundamental statement of EMS-trauma interdependence.
- Trauma centers not yet designated
- Trauma System Plan under development but not implemented
- No trauma registry
- No mandatory autopsy law
- Undercompensated trauma care unquantified and unfunded
Recommendation language:
- Designate trauma centers “as soon as feasible”
- Proceed with Trauma System Plan implementation “immediately and irrespective of the status of funding support for undercompensated trauma care”
- Develop trauma registry with prehospital data compatibility
- Develop mandatory autopsy law
- Study and fund undercompensated trauma care
- Enhance “default hospitals” capability for prehospital patients
- Establish simplified inter-hospital transfer system (COBRA-consistent)
- Strengthen access-to-care laws requiring hospitals to accept all emergency referrals
Report characterization (inferred): Pre-trauma-system. The urgency of “immediately and irrespective of funding” is notable — the TAT explicitly decouples system implementation from funding resolution, suggesting funding debates were being used to delay action.
3H. Medical Direction
Inferred from recommendations:
- Physician involvement not achieved in “all aspects of EMS”
- No board-certified emergency medicine physician as state EMS medical director
- Local physician medical direction underdeveloped — needs “educational and technical resources”
- Liability issues for medical direction unresolved
- No rules mandating medical direction for BLS
- No rules defining medical director requirements/responsibilities in EMS statutes
Recommendation language:
- Achieve physician involvement in all aspects of EMS
- Appoint “a board-certified emergency medicine physician in active practice as state EMS medical director”
- Support local medical direction development with educational/technical resources
- Address medical direction liability issues
- Mandate medical direction for BLS
- Define medical director requirements and responsibilities in rules/regulations
Report characterization (inferred): No state EMS medical director, no BLS medical direction mandate, and no statutory framework for medical director requirements. The specification of “board-certified emergency medicine physician in active practice” is the most prescriptive medical director qualification recommendation in the corpus.
3I. Communications and Infrastructure
Inferred from recommendations:
- No state EMS communications plan
- No assigned agency for emergency communications coordination (including 911)
- Prehospital providers lack required communication capabilities with hospitals
- No uniform EMS dispatching requirements
- Multiple agency types (law enforcement, fire, EMS) handling medical calls without standardization
Recommendation language:
- Develop state EMS communications plan
- Establish or assign agency for all emergency communication coordination including 911
- Require prehospital communication capabilities with hospitals and medical direction
- Adopt statewide uniform EMS dispatching requirements applicable to all agencies receiving medical calls or dispatching EMS
Report characterization (inferred): No communications infrastructure framework. The recommendation for a single agency coordinating all emergency communications including 911 is structurally ambitious for 1990.
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
N/A — initial assessment.
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall System Characterization
The newsletter summary frames the recommendations as “critical” and notes many were “already Bureau and Texas Department of Health action items” — suggesting alignment between the TAT’s findings and existing institutional priorities. The standard-of-excellence framing explicitly depoliticizes the assessment (“not against any other state”).
Structural Barriers Inferred
- No trauma center designation — pre-system
- No state EMS medical director (board-certified EM physician specified)
- No statewide data system — seven evaluation recommendations
- No EMS communications plan or coordinating agency
- Bureau under-positioned organizationally
- Comprehensive rules package pending but unadopted
- No minimum staffing standard (EMT-Basic not required)
- No standardized training curriculum/oversight
- No medical direction mandate for BLS
- No trauma registry
- Undercompensated trauma care unquantified
- Medicaid reimbursement inadequate
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
Earliest Report in Corpus
At January 1990, this is the earliest assessment in the corpus, predating Montana 1991 by 18 months. It captures EMS system development in a major state (2nd largest by area and population) at the dawn of the NHTSA assessment program era.
TAT Member Continuity: W. Daniel Manz
Dan Manz appears on this 1990 Texas TAT, the 1999 Alaska TAT, the 2022 Georgia TAT, the 2024 Kentucky TAT, and the 2024 Idaho TAT — a 34-year span of NHTSA TAT participation (1990–2024). This extends the previously documented 25-year range. Manz’s role in 1990 (Vermont EMS Director) represents the earliest known career data point in the corpus.
“Good Trauma System Is Only a Small Component”
The preserved TAT quote — “a good trauma system is only a small component of the EMS system in which it exists” — is a foundational principle that implicitly critiques trauma-centric policy approaches. It asserts EMS system primacy over trauma system development, a perspective that recurs across decades of assessments.
Most Prescriptive Medical Director Qualification
The recommendation to appoint “a board-certified emergency medicine physician in active practice” as state EMS medical director is the most specific credential requirement recommended in any report analyzed. Other reports recommend a state medical director without specifying board certification or active practice.
“Immediately and Irrespective of Funding”
The recommendation to proceed with Trauma System Plan implementation “immediately and irrespective of the status of funding support for undercompensated trauma care” is the most explicit decoupling of system development from funding resolution in the corpus. It suggests the TAT observed funding debates being used as a barrier to action.
Newsletter Format Limitations
This is the most limited source document in the corpus — a 2-page newsletter summary with recommendations only. No Status narratives, no data points, no direct TAT language (except one preserved quote), no system description, no geographic context, no workforce numbers. The analysis should be treated as a recommendations-only extraction and replaced if the full report surfaces.
Pre-Modern EMS Era
Texas 1990 predates NEMSIS, the National Scope of Practice Model, the EMS Agenda for the Future (1996), the EMS Education Agenda for the Future, the EMS Compact, and essentially all modern EMS infrastructure standards. The recommendations represent the foundational building blocks: designate trauma centers, create a data system, adopt rules, mandate medical direction, standardize training. These same recommendations appear in varying states of completion across all subsequent reports in the corpus.
Analysis completed per standardized NHTSA State EMS Assessment framework. Document limitations acknowledged — recommendations-only extraction from newsletter summary. No synthesis or editorial interpretation has been applied beyond inferences explicitly noted.
Wisconsin
Full Analysis
Wisconsin 2012 NHTSA Reassessment — Structured Analysis
SECTION 1: REPORT IDENTIFICATION
- State: Wisconsin
- Report type: Reassessment
- Date of site visit: June 25–28, 2012 (title page says June 25–28; Background text says June 26–28)
- Year of publication: 2012
- Prior assessment year: 2001 (Reassessment); original assessment 1990 (Introduction, p.8: "In 1990 and again in 2001 Wisconsin requested a NHTSA assessment")
- TAT members:
- Theodore R. Delbridge, MD, MPH, FACEP
- Christoph R. Kaufmann, MD, MPH, FACS
- D. Randy Kuykendall, MLS
- Susan D. McHenry, MS
- Jolene R. Whitney, MPA
- NHTSA facilitator: Susan D. McHenry, MS (listed as TAT member; no separate facilitator distinguished)
- Number of presenters/briefings: Over 30 presenters over the first day and a half (Background, p.5)
- Requesting agency: Wisconsin Department of Health Services, Emergency Medical Services Unit
SECTION 2: STATE CONTEXT
- Population (as cited in report): Not documented in this report — no population figure stated
- Geographic characteristics: Described as "a large state" (Transportation); blend of "vibrant urban communities, world-class university towns, or small rural villages" (Introduction, p.8); approximately 75% of EMS ambulance services are rural-based (Transportation)
- Number of counties/jurisdictions: 72 counties (Communications: 71 of 72 counties have enhanced 9-1-1)
- EMS system overview:
- EMS Board: 11 members, appointed by Governor — described as a "working board"
- 792 licensed or certified EMS services: 341 certified first responder groups, 147 licensed basic ambulance, 144 licensed intermediate technician ambulance, 15 licensed intermediate ambulance, 136 licensed paramedic ambulance, 9 licensed air medical services
- ~1,500 registered ambulance vehicles
- 64% volunteer, 36% career service personnel
- 75% rural-based; 46% fire-based; 54% private, independent, or volunteer-based
- Over 20,000 certified EMS providers
- Over 500,000 ambulance patients per year
- 9 Regional Trauma Advisory Councils (RTACs)
- EMS Unit: 8 FTE employees
- Wisconsin DOT separately responsible for ambulance inspections
- Notable demographic or socioeconomic factors cited: Strong volunteer ethic — "an enthusiasm for volunteerism that creates an unparalleled quality of life" (Introduction). No specific socioeconomic data cited.
SECTION 3: STRUCTURAL FINDINGS — THEMATIC EXTRACTION
3A. Statewide EMS Plan
(a) Direct quotes:Wisconsin has a statewide EMS plan that was originally written in 1995, and is updated on a biannual basis. There are 33 priorities identified in the plan, and the latest draft of the plan is dated 2012." (Resource Management, p.14)
The plan lacks measurable milestones and strategic planning to achieve these priorities, and it does not identify responsible agencies for completing the tasks necessary to address its priority areas." (Resource Management, p.14)(b) Data points: Statewide EMS plan EXISTS (since 1995, updated biennially, latest draft 2012). Contains 33 priorities. Lacks measurable milestones, strategic methodology, and assignment of responsible agencies. (c) TAT characterization: Acknowledged as existing but characterized as lacking operational rigor. (d) Priority recommendation: The EMS Unit should develop strategic methodology to support its EMS Plan objectives, complete with timelines, objectives, and identification of responsible agencies.
3B. Funding and Financial Sustainability
(a) Direct quotes:State funding of EMS interests has decreased, not just in relative terms adjusted for inflation, but in meaningful absolute terms." (Introduction, p.8)
EMS has been demoted within the governmental bureaucracy to the extent that infrastructural erosion may be a threat to the future of the State's EMS system." (Introduction, p.8)
The budget for operation of the EMS Unit is woefully small for a system of this magnitude." (Regulation and Policy, p.11)
The Funding Assistance Program (FAP) is the most significant contribution of state resources to the statewide EMS system but the dollars available have decreased while costs of equipment and education have increased." (Regulation and Policy, p.11)
The amount of funding provided to the EMS Unit for its daily operations and the amount allocated to the FAP is below what might be expected in a state the size of Wisconsin." (Resource Management, p.14)
Many EMS system stakeholders across the state see the lack of funding and lack of legislative action on EMS Board recommendations as prime indicators that there is a general lack of interest in the legislature and in state government when it comes to providing quality EMS care." (Resource Management, p.14)(b) Data points:
- EMS Unit: 8 FTE employees
- Annual budget: mixture of state and federal grant funds (no specific dollar amount cited for EMS Unit operating budget)
- Funding Assistance Program (FAP): dollars have decreased in absolute terms
- Trauma system funding: appropriations of $94,300 for trauma classification reviews and $449,200 for RTAC operations
- Funding sources: General Purpose Revenue (GPR), transportation safety funds, Wisconsin Hospital Preparedness grant
- State EMS Medical Director funded at $25,000 (interpreted as the ceiling)
- No specific total EMS budget cited
- Tuition for EMS education: $126 per credit hour covers approximately 1/3 of actual costs
- Legislature should provide sufficient and sustainable financial resources to support the Section and Units
- Division, Department, and Legislature should take "immediate steps" to find additional stable funding
- Work to secure permanent funding for trauma care system function
3C. Workforce — Recruitment, Retention, and Staffing
(a) Direct quotes:Wisconsin EMS depends on a high number of volunteer EMS providers, particularly in rural areas, to maintain system effectiveness and availability. Concerns regarding the ability of volunteer EMS agencies to maintain their current level of service are valid and deserve attention." (Human Resources, p.18)
Wisconsin EMS agencies are experiencing difficulties with the recruitment and retention of volunteers, especially in efforts to recruit minority volunteers." (Resource Management, p.14)
Across the state, individual services may be in continual flux as the immediate availability of volunteer personnel changes." (Evaluation, p.39)(b) Data points:
- Over 20,000 certified EMS providers
- Over 500,000 ambulance patients per year
- 64% volunteer, 36% career service personnel
- 792 licensed/certified EMS services
- 12 paramedic training programs; 4 of 12 hold CAAHEP accreditation (remaining 8 expected to achieve by regulatory deadline)
- CAAHEP accreditation required for all paramedic programs by January 1, 2013
- Tuition ($126/credit) covers only ~1/3 of actual cost; services concerned about cost shift
- Increasing educational time requirements documented as a concern
- Insufficient clinical and field preceptor sites
- Preceptors required to have minimum 2 years experience
- Critical care paramedic level implementation concern — date may be unrealistic, personnel insufficient
- Develop strategy to understand and document barriers to volunteer recruitment/retention
- Develop distributive learning methodologies to minimize classroom hours
- Partner with WTCS for alternative clinical opportunities
- Comprehensive evaluation of EMS instructor cadre
3D. Essential Service Designation
(a) Direct quotes:A pervasive issue to be overcome is lack of recognition of the critical societal role served by EMS and its appropriate stature in governmental organization and priorities." (Introduction, p.8)(b) Data points: The term "essential service" does not appear in the report. (c) TAT characterization: The Introduction frames EMS as lacking recognition of its "critical societal role" and its "appropriate stature in governmental organization and priorities." This is functionally an observation about the absence of essential service status without using the specific term. (d) Priority recommendation: Not recommended using the term "essential service."
3E. Regulatory Fragmentation
(a) Direct quotes:The Wisconsin Department of Transportation (DOT) continues to have statutory responsibility for the inspection of ambulances while the Section and the EMS Unit are responsible for the licensing of these services. This bifurcation of responsibility and authority remains problematic in terms of consistency in application and enforcement." (Regulation and Policy, p.11)
Though air medical services remain unregulated, there are some basic requirements for air medical services in the administrative rule revision. Wisconsin does not have a coordinated air response system." (Transportation, p.21)
The EMS Unit is obviously understaffed and in many cases there is evidence of its inability to fully monitor, oversee and enforce EMS regulations across the state." (Resource Management, p.13)(b) Data points:
- Ambulance inspection: DOT (vehicles inspected once every 2 years by state patrol)
- Ambulance licensing: EMS Unit (Department of Health Services)
- Air medical services: 9 licensed — largely unregulated; Air Medical Council self-regulates
- 176 PSAPs statewide; approximately 130 dispatch EMS; only 68 have EMD systems
- No statutory authority for EMS Unit to regulate dispatch
- No standards for first response groups
- No driving safety training required for ambulance vehicle drivers
- Equipment list (TRANS 309) not updated for over 12 years and resides in DOT administrative rule
- Each of 792 agencies responsible for identifying own medical director — no ability to verify qualifications
- Private EMS providers cannot participate in MABAS mutual aid system
- Legislature should consolidate ambulance inspection and licensing within Department of Health Services
- Legislature should create consolidated EMS/Trauma/Preparedness regions based on RTAC boundaries
- Legislature should provide statutory authority for statewide EMD system
- Mandate emergency vehicle operations training for ambulance drivers
3F. Data and Evaluation Systems
(a) Direct quotes:Efforts to conduct meaningful evaluation and ensure statewide EMS quality improvement initiatives remain largely underdeveloped." (Evaluation, p.39)
There remain substantial concerns about the quality of some data elements, and as much as 18% may be unusable." (Evaluation, p.39)
On a statewide basis there is little ability to evaluate outcomes related to EMS care." (Evaluation, p.39)
Many hospitals do not provide outcomes information as a matter of policy." (Evaluation, p.39)
The Unit's and local providers' abilities to develop meaningful performance improvement processes are hindered by the lack of statutory protection from legal discovery." (Regulation and Policy, p.11)(b) Data points:
- Wisconsin Ambulance Run Data System (WARDS) — NEMSIS compliant, replaced previous WEMSIS system
- Over 500,000 patient care reports received per year
- Up to 18% of data may be unusable due to quality issues
- 7-day window allowed for final EMS report submission
- Four basic standardized reports available to EMS providers; others await development
- Providers can query their own data but cannot make comparisons to similar systems
- Trauma registry supported by DOT; being aligned with NTDS
- Level I and II trauma centers submit to NTDB
- State, regional, and hospital-specific trauma reports "have not been generated at the state level"
- No data linkage between prehospital data and hospital outcomes
- EMS peer review NOT protected from discovery in civil matters (trauma peer review IS protected)
- Plans to hire epidemiologist for data analysis
- No EMS data manager position exists
- Legislature should protect EMS-related peer review from discovery in civil procedures
- Require all licensed hospitals to provide meaningful outcomes information for EMS patients
- Develop and fund position of EMS data manager and technical advisor
- Continue to remedy data integrity issues
- Develop comparative standard reports
- Submit WARDS data to National EMS Database
3G. Trauma System Status
(a) Direct quotes:In 2008, Wisconsin began implementation of a statewide trauma system; 122 of 127 acute care hospitals currently participate." (Facilities, p.23)
This voluntary inclusive approach does not limit the number of Level I and II trauma centers, except as dictated by trauma patient volume requirements. This process may result in too many Level II facilities within a defined geographic area." (Facilities, p.23)
Although the system currently functions without statutory funding, there are appropriations of $94,300 for trauma classification reviews and $449,200 for RTAC operations." (Trauma Systems, p.35)(b) Data points:
- Statewide trauma system: statutory authority since 2005 (administrative rule OHS 118); implementation began 2008
- 122 of 127 acute care hospitals participating (inclusive, voluntary)
- 2 Level I trauma centers (ACS verified)
- 2 Level I pediatric trauma centers (ACS verified)
- 8 Level II trauma centers (ACS verified)
- 1 Level II pediatric trauma center (ACS verified)
- 109 Level III and Level IV centers (state classification process)
- Three-year verification/classification cycle
- 9 RTACs and RTAC Coordinators
- State Trauma Advisory Council (STAC) — created by statute, active since 2000
- Trauma plan written 2001 — now out of date; administrative rules reference ACS 1999 document (outdated)
- Appropriations: $94,300 for trauma classification reviews; $449,200 for RTAC operations
- Funded by GPR, transportation safety funds, Wisconsin Hospital Preparedness grant
- No State Trauma Medical Director
- No dedicated funding for uncompensated trauma care
- No formal hospital designation process for STEMI, stroke, burns, or special populations
- WI-Trac patient tracking system in pilot phase
- Statewide trauma triage and transport guideline: newly updated and approved by EMS Board and STAC; implementation pending
- Update trauma administrative rules consistent with current ACS standards
- Update trauma plan consistent with HRSA Model Trauma System Planning and Evaluation document
- Secure permanent funding for trauma system
- Access additional personnel and financial resources for trauma registry data utilization
- Create position and hire a State Trauma Medical Director
- Broaden STAC representation (adding flight support, rehabilitation, consumer representation)
- Improve communication between STAC and EMS Board
- Use RTAC regional model for MCI/terrorism response organization
3H. Medical Direction
(a) Direct quotes:The nature of EMS medical direction in Wisconsin is both a great advantage for the system and a challenge for future efforts to ensure statewide quality and reliability." (Medical Direction, p.31)
While Chapter 256 establishes that there shall be a state EMS medical director, it does not endow him with any specific responsibilities or authorities. Further, it designates a specific funding source for $25,000, which has been interpreted as the ceiling of available funding for the position." (Medical Direction, p.31)
Thus, the state EMS medical director serves as only a small fraction of a full-time equivalent and functions mostly in a limited advisory capacity at the discretion of the EMS Unit." (Medical Direction, p.32)
There is an undesirable degree of heterogeneity among EMS medical directors throughout Wisconsin. Differences include EMS-related fund of knowledge, commitment to the system, and motivation. The results include decisions about care and protocols with variation that cannot be explained by patients' best interests." (Medical Direction, p.32)
There is not a reliable way to efficiently communicate with all EMS medical directors, nor is there a readily available roster of who they are." (Medical Direction, p.32)
Due to local medical direction inadequacies, services are sometimes forced to transport patients to the local hospital, even those with time critical diagnoses. Many small hospitals that provide medical control require the EMS agency to bring the patient to their facility first, even if not in the best interest of the patient." (Facilities, p.24)(b) Data points:
- State EMS Medical Director: EXISTS — established in Chapter 256, contracted, "engaged and well-qualified"
- Funded at $25,000 — interpreted as ceiling; "a small fraction of a full-time equivalent"
- No specific responsibilities or authorities in statute
- No State Trauma Medical Director (recommended as separate position)
- 792 EMS agencies each responsible for identifying own medical director
- No ability to verify medical director qualifications
- No reliable roster of medical directors; no efficient communication mechanism
- Online medical director orientation course exists but cannot determine who has taken it
- No prescribed qualifications for physicians providing online medical control
- Physician Advisory Committee: valuable resource but limited by funding; meeting frequency restricted
- Establish State EMS Medical Director as 0.5 FTE with commensurate compensation and support
- Clarify responsibilities and authorities of the position in statute
- Develop a system of regional EMS medical direction with qualified cadre
- Develop and maintain roster of all EMS medical directors
- Ensure Physician Advisory Committee meets at least bi-monthly
3I. Communications and Infrastructure
(a) Direct quotes:Emergency Medical Dispatch is used sporadically throughout the state. Lack of medically driven dispatch techniques with pre-arrival instructions allows for inappropriate EMS response and a less than optimal use of resources due to over-triage." (Resource Management, p.14)(b) Data points:
- E9-1-1 coverage: 99% of population; 71 of 72 counties with enhanced 9-1-1
- 176 PSAPs statewide; ~130 dispatch EMS; only 68 have EMD systems
- PSAPs reluctant to train EMD due to cost, liability, and staffing shortages
- VHF radios for day-to-day operations; trunked systems in some urban settings
- All hospitals required by statute to maintain common radio communications system
- Statewide public safety communications system with dedicated EMS talk groups (funded by Homeland Security Interoperability Program)
- EMS Communications Plan developed; scheduled for update in 2012
- Mutual Aid Box Alarm System (MABAS) established — private providers excluded
- WI-Trac system for hospital diversion/bed capacity (not all PSAPs participate)
- No medical oversight for dispatch centers or dispatching personnel
- Governor-appointed panel authorized to establish dispatch standards committee
- Statewide 9-1-1 board being formed
- No coordinated air response system; no air activation guidelines
- EMS Unit and EMS Board should participate in creating statutory authority for EMD standards and regulations
- Complete development of online medical control and resource hospital standards
- Continue integrating EMS agencies, dispatch centers, and hospitals on WI-Trac
- Develop standardized air activation guidelines
- Investigate call center models for interfacility transfers and air ambulance activation
3J. Preparedness
(a) Direct quotes:The EMS Unit realignment into the Emergency Health Care and Preparedness Section offers the opportunity to greatly improve overall EMS preparedness in the state." (Preparedness, p.41)
Continued integration must be done in a way that does not create a dependency upon federal funding to provide basic EMS preparedness." (Preparedness, p.42)(b) Data points:
- Section provides respirator mask fit testing, Advanced Burn Life Support training
- PPE stockpile, medical countermeasures stockpile, and decontamination resources maintained
- EMAC exercised with other states; NIMS compliance observed
- Mass casualty plans and statewide hospital surge plan include EMS
- WI-Trac patient tracking system can interface with EMS patient care reporting
- 7-day EMS report submission window limits surveillance capability
- H1N1 response: HPP, PHP, and EMS collaborated on vaccination campaign
- Legal issues surrounding Alternate Standards of Care unresolved
- Diverse opinions on statewide MCI triage systems
- Private EMS agencies not incorporated into mass casualty response plan
- Leverage resources without creating federal funding dependency
- Require shorter EMS report submission timeframe for surveillance
- Resolve legal issues on alternate standards of care
- Adopt a standard MCI triage method using Model Uniform Core Criteria
- Incorporate private EMS agencies into MCI response plan
SECTION 4: PROGRESS ON PRIOR RECOMMENDATIONS
This is a reassessment. Original assessment: 1990. First reassessment: 2001. This is the second reassessment (2012) — Wisconsin is "among only a few states to have initiated such self-reflection and invited repeated external evaluation" (Introduction, p.8).
Using the resulting collective recommendations as a guide, Wisconsin has made tremendous strides in improving its EMS system during the past 22 years." (Introduction, p.8)Key progress documented since 2001:
- Statewide trauma system implemented (statutory authority 2005; implementation 2008) with 122 of 127 hospitals participating
- Administrative rules (OHS 110) updated for EMS licensing, certification, training
- WARDS data system implemented (NEMSIS compliant, replacing WEMSIS)
- Wisconsin Air Medical Council organized
- CAAHEP accreditation requirement for paramedic programs adopted (deadline 2013)
- National EMS Education Standards and Scope of Practice adopted
- Statewide interoperable communications system funded and developed
- E9-1-1 coverage expanded to 99% of population
- WI-Trac patient tracking system piloted
- EMS Communications Plan developed
- Statewide trauma triage and transport guideline updated and approved
- Increased collaboration between DOT Bureau of Transportation Safety and EMS Unit
- DOT/DHS bifurcation of ambulance inspection/licensing persists from at least 2001
- State EMS Medical Director position still funded at $25,000 with no statutory authority
- EMS Unit still understaffed (8 FTEs)
- FAP funding has decreased in absolute terms
- No EMD standards or dispatch certification
- No peer-review protection for EMS data
- No statewide transportation plan
- Volunteer recruitment/retention remains a concern
- Air medical services remain largely unregulated
SECTION 5: REPORT TONE AND INSTITUTIONAL CHARACTERIZATION
Overall characterization:A pervasive issue to be overcome is lack of recognition of the critical societal role served by EMS and its appropriate stature in governmental organization and priorities." (Introduction, p.8)
The accomplishments have resulted from the dedication of countless volunteers and unrecognized efforts of committed professionals. At the same time, State funding of EMS interests has decreased, not just in relative terms adjusted for inflation, but in meaningful absolute terms. Further, EMS has been demoted within the governmental bureaucracy to the extent that infrastructural erosion may be a threat to the future of the State's EMS system." (Introduction, p.8)
Nevertheless, the spirit of Wisconsin EMS is alive and prepared to persevere to maintain the quality of life the people of Wisconsin so richly enjoy." (Introduction, p.8)Structural barriers identified:
- DOT/DHS statutory bifurcation of ambulance inspection and licensing
- State EMS Medical Director position with $25,000 ceiling and no statutory authorities
- Absence of peer-review protection for EMS data (trauma data is protected)
- "Demotion" of EMS within governmental bureaucracy
- 792 agencies each identifying own medical director with no verification mechanism
- Legislative inaction on EMS Board recommendations
- Hospital policies refusing to provide outcomes information
The report references the 2006 IOM Report in the Background. EMS is explicitly framed as a healthcare system concern: reducing "morbidity and mortality" and providing "uniform quality among diverse communities." The DOT's continuing role in ambulance inspection is implicitly treated as a legacy of the transportation framework.
Federal funding mechanisms:- Highway safety funds referenced as original TAT funding mechanism
- Bureau of Transportation Safety supported the assessment
- NHTSA 402 funds specifically referenced in Transportation recommendations: "The Section should seek (NHTSA 402) funds to support a statewide transportation needs assessment"
- Homeland Security Interoperability Program funds for communications
- Hospital Preparedness Program grant funds
- EMSC federal funding
- Warning against creating "dependency upon federal funding" for basic EMS preparedness
- Inclusive trauma system with 122 of 127 hospitals participating
- Strong volunteer ethic and commitment
- EMS Board as a "working board" producing products where state resources are lacking
- Updated administrative rules (OHS 110)
- WARDS data system (NEMSIS compliant)
- Near-universal E9-1-1 coverage (99%)
- Statewide interoperable communications system
- 9 RTACs with coordinators
- Trauma peer review protected by statute
- Engaged State EMS Medical Director (despite funding limitations)
- Wisconsin is one of only a few states to undergo three NHTSA assessments
- Good working relationship between EMS Unit and Bureau of Transportation Safety
- State funding decreased in absolute terms; EMS "demoted" within bureaucracy
- EMS Unit budget "woefully small" with only 8 FTEs
- State EMS Medical Director funded at $25,000 with no authorities
- No State Trauma Medical Director
- DOT/DHS bifurcation of ambulance oversight
- Air medical services largely unregulated
- No EMD standards; only 68 of ~130 dispatching PSAPs have EMD
- Up to 18% of WARDS data may be unusable
- No EMS peer-review protection (unlike trauma)
- Volunteer recruitment/retention difficulties, especially minorities
- Legislative inaction on EMS Board recommendations
- Hospitals refusing to provide outcomes data
- Local medical directors overriding statewide protocols against patients' best interests
SECTION 6: NOTABLE FINDINGS AND ANOMALIES
"Demoted Within the Governmental Bureaucracy"
The TAT's characterization of EMS as having been "demoted within the governmental bureaucracy to the extent that infrastructural erosion may be a threat to the future of the State's EMS system" is among the most striking institutional characterizations in the corpus. The report documents both absolute dollar decreases and organizational restructuring (from "Bureau of EMS" to a unit within a section) as evidence of demotion.
$25,000 State EMS Medical Director
The State EMS Medical Director position is established in statute but funded at $25,000, interpreted as a ceiling. This produces "a small fraction of a full-time equivalent" functioning "mostly in a limited advisory capacity." The TAT recommended expanding to 0.5 FTE. This is among the lowest-funded State EMS Medical Director positions documented in the corpus.
Three NHTSA Assessments (1990, 2001, 2012)
Wisconsin is identified as "among only a few states to have initiated such self-reflection and invited repeated external evaluation." The 22-year longitudinal window provides a uniquely long baseline for tracking system development.
EMS Board as Substitute for State Capacity
The EMS Board is described as a "working board" that "has actually performed work that could not be completed by the EMS Unit due to lack of resources." This represents an unusual adaptation where a volunteer advisory body compensates for governmental underinvestment — a pattern the TAT notes produces frustration when EMS Board products fail to generate legislative action.
Inclusive Trauma System at 96% Hospital Participation
122 of 127 acute care hospitals (96%) participate in the voluntary inclusive trauma system, which is an extremely high participation rate for a voluntary system. However, the system's administrative rules reference ACS 1999 standards (outdated by 13 years at the time of assessment), and neither state-level nor regional trauma reports have been generated from the registry.Local Medical Directors Overriding Statewide Protocols
The report documents local medical directors and small hospitals requiring EMS agencies to transport patients to their facility "even if not in the best interest of the patient," specifically overriding statewide trauma triage and transport protocols. The TAT describes this as online medical control being "too often used to overrule EMS personnel discretion regarding destination choice based on patient condition."
18% Data Unusable
Up to 18% of WARDS data may be unusable due to poor data entry and technical incompatibility between WARDS and proprietary vendor bridging programs. This is one of the more specific data quality metrics documented across the corpus.
Private EMS Excluded from Mutual Aid and MCI Plans
Private EMS providers cannot participate in the Mutual Aid Box Alarm System (MABAS) and are not incorporated into the overall mass casualty response plan. This structural exclusion of a segment of the EMS workforce from both routine mutual aid and disaster response is notable.
NHTSA 402 Funds Explicitly Referenced
The report explicitly recommends seeking "NHTSA 402 funds" for a statewide transportation needs assessment — one of the few direct references to Section 402 highway safety funds in a post-2006 IOM Report assessment.
Analysis produced using standardized NHTSA State EMS Assessment extraction framework. All quotes are from the Wisconsin 2012 Reassessment report. No editorial synthesis applied.
Corpus Overview
This table lists the 29 NHTSA state EMS assessment and reassessment reports obtained for this archive, listed chronologically. All were located through public records searches, state websites, internet archives, libraries, and state public records requests. Additional assessments may exist but could not be publicly located; NHTSA does not maintain a central public repository for these reports. All reports listed were produced by independent Technical Assessment Teams assembled by NHTSA’s Division of Emergency Medical Services (later Office of EMS). The reports are consensus documents; neither NHTSA nor the assessed state reviewed or approved the content prior to release.
| # | State | Year | Type | Prior Assessment | Interval | NHTSA Facilitator |
|---|---|---|---|---|---|---|
| 1 | Texas | 1990 | Assessment | N/A | — | John L. Chew, Jr. |
| 2 | Montana | 1991 | Assessment | N/A | — | Valerie A. Gompf |
| 3 | Massachusetts | 1992 | Assessment | N/A | — | Valerie A. Gompf |
| 4 | Colorado | 1997 | Reassessment | 1988 | 9 yr | Susan McHenry |
| 5 | Alaska | 1999 | Reassessment | 1992 | 7 yr | Susan McHenry |
| 6 | California | 1999 | Assessment | N/A | — | Susan D. McHenry |
| 7 | Connecticut | 2000 | Reassessment | 1991 | 9 yr | Susan McHenry, MS |
| 8 | South Dakota | 2002 | Reassessment | 1994 | 8 yr | Susan McHenry |
| 9 | Maryland | 2004 | Reassessment | 1991 | 13 yr | Susan McHenry |
| 10 | Mississippi | 2004 | Reassessment | 1991 | 13 yr | Susan D. McHenry |
| 11 | Montana | 2005 | Reassessment | 1991 | 14 yr | Susan D. McHenry, MS |
| 12 | Oregon | 2006 | Reassessment | 1992 | 14 yr | Susan D. McHenry |
| 13 | Kansas | 2007 | Reassessment | 1994 | 13 yr | David W. Bryson |
| 14 | Michigan | 2007 | Reassessment | 1991 | 16 yr | Susan D. McHenry |
| 15 | Nevada | 2009 | Reassessment | 1991 | 18 yr | Susan D. McHenry |
| 16 | Oklahoma | 2009 | Reassessment | 1992 | 17 yr | Susan D. McHenry |
| 17 | Missouri | 2010 | Reassessment | 1994 | 16 yr | Susan D. McHenry, MS |
| 18 | Ohio | 2011 | Reassessment | 2001 | 10 yr | Susan D. McHenry, MS |
| 19 | Wisconsin | 2012 | Reassessment | 2001 | 11 yr | Susan D. McHenry, MS |
| 20 | Connecticut | 2013 | Reassessment | 2000 | 13 yr | Susan McHenry, MS |
| 21 | Florida | 2013 | Reassessment | 1993 | 20 yr | Susan McHenry, MS |
| 22 | Alaska | 2014 | Reassessment | 1999 | 15 yr | Susan McHenry, MS |
| 23 | Iowa | 2015 | Reassessment | Not stated | — | Susan McHenry, MS |
| 24 | Michigan | 2017 | Reassessment | 2007 | 10 yr | Susan McHenry, MS |
| 25 | New Hampshire | 2018 | Reassessment* | Not stated | — | Not listed |
| 26 | Hawaii | 2019 | Reassessment | Not stated | — | Dave Bryson |
| 27 | Georgia | 2022 | Reassessment | 1995 | 27 yr | Dave Bryson |
| 28 | Idaho | 2024 | Reassessment | 1993 | 31 yr | Dave Bryson |
| 29 | Kentucky | 2024 | Reassessment | 1991 | 33 yr | Dave Bryson |
*Executive summary only; full TAT report not obtained. TAT composition and NHTSA facilitator not listed in the executive summary document.
Assessment Intervals Are Growing
The intervals between initial assessment and reassessment have lengthened over the life of the program. Early reassessments occurred at 7–13 year intervals. Recent reassessments have gaps of 27 years (Georgia), 31 years (Idaho), and 33 years (Kentucky).
Four states (Alaska, Connecticut, Michigan, Montana) were assessed twice within the corpus, providing within-state longitudinal comparison. The Montana pair (1991→2005) is uniquely valuable: two TAT members (McGinnis and Phillips) served on both teams, providing 14 years of direct institutional memory.
TAT Composition Analysis
A total of 53 unique individuals served on the 29 assessment teams (excluding New Hampshire, which does not list team composition). Four NHTSA facilitators coordinated 28 of 29 assessments. The table below shows individuals appearing on two or more teams.
NHTSA Facilitators
Most Frequent TAT Members
Table lists individuals appearing on two or more assessment teams. The full list of all 49 unique team members is available in the individual report analyses above.
The 1995 NHTSA Program Evaluation: 40-State Crosswalk
In April 1995, NHTSA published EMS System Development: Results of the Statewide EMS Assessment Program (DOT HS 808271), covering 40 state assessments conducted between February 1988 and September 1994. That same year, Snyder et al. published the only peer-reviewed analysis of the program in the Annals of Emergency Medicine (25(6):768–775), reviewing 35 of those assessments.
Together, these documents form the primary baseline against which subsequent assessments can be evaluated. Of the 40 states in the 1995 baseline, 20 (50%) appear in this archive with subsequent reassessments that could be obtained.
| State | Original Assessment | In This Archive? | Subsequent Assessment(s) |
|---|---|---|---|
| Alabama | Feb 1991 | No | — |
| Alaska | Sep 1992 | Yes | 1999, 2014 |
| Arizona | Sep 1990 | No | — |
| Arkansas | Nov 1989 | No | — |
| Colorado | Dec 1988 | Yes | 1997 |
| Connecticut | May 1991 | Yes | 2000, 2013 |
| Delaware | Jun 1993 | No | — |
| Florida | Aug 1993 | Yes | 2013 |
| Hawaii | Apr 1991 | Yes | 2019 |
| Idaho | Apr 1993 | Yes | 2024 |
| Illinois | Nov 1990 | No | — |
| Indiana | Aug 1989 | No | — |
| Iowa | Nov 1991 | Yes | 2015 |
| Kansas | Apr 1994 | Yes | 2007 |
| Kentucky | Apr 1991 | Yes | 2024 |
| Louisiana | Jun 1989 | No | — |
| Maryland | Aug 1991 | Yes | 2004 |
| Massachusetts | Mar 1992 | Yes | 1992 (in corpus) |
| Michigan | Jan 1991 | Yes | 2007, 2017 |
| Minnesota | Dec 1989 | No | — |
| Mississippi | Jun 1991 | Yes | 2004 |
| Montana | Jun 1991 | Yes | 1991 + 2005 |
| Nevada | Aug 1991 | Yes | 2009 |
| New Hampshire | Jun 1990 | Yes | 2018* |
| New Jersey | Oct 1993 | No | — |
| New Mexico | Sep 1994 | No | — |
| New York | Apr 1992 | No | — |
| North Carolina | Jul 1990 | No | — |
| North Dakota | Nov 1992 | No | — |
| Ohio | Dec 1990 | Yes | 2011 |
| Oklahoma | Apr 1992 | Yes | 2009 |
| Oregon | May 1992 | Yes | 2006 |
| Pennsylvania | Feb 1990 | No | — |
| South Dakota | Apr 1994 | Yes | 2002 |
| Texas | Jan 1990 | No | — |
| Utah | Dec 1992 | No | — |
| Virginia | Aug 1992 | No | — |
| West Virginia | Jul 1992 | No | — |
| Wisconsin | Nov 1990 | Yes | 2012 |
| Wyoming | Mar 1989 | No | — |
*Executive summary only. Five additional states in the current archive (California, Missouri, Georgia, and two with post-September 1994 assessments) were not part of the 1995 evaluation but are included in the current corpus.
Baseline Documents
- National Highway Traffic Safety Administration. EMS System Development: Results of the Statewide EMS Assessment Program. Washington, DC: US Department of Transportation (DOT HS 808271); April 1995. Digitized by Google; available through the HathiTrust Digital Library and select federal document depositories.
- Snyder JA, Baren JM, Ryan SD, Chew JL, Seidel JS. Emergency medical service system development: Results of the statewide emergency medical service Technical Assessment Program. Ann Emerg Med. 1995;25(6):768–775. The only peer-reviewed analysis of the NHTSA assessment program. Co-authored by Susan D. Ryan of the NHTSA EMS Division.
Extraction Methodology
Each report in this archive was analyzed using a standardized extraction framework mirroring the ten component areas used by NHTSA Technical Assessment Teams: Regulation and Policy, Resource Management, Human Resources and Training, Transportation, Facilities, Communications, Public Information and Education, Medical Direction, Trauma Systems, and Evaluation (with Preparedness added to assessments conducted after 2001).
For each component area, the extraction captured:
The structured analyses also extract additional dimensions not present in the ten-component framework: essential service designation status, regulatory fragmentation, progress on prior recommendations (where documented), report tone and institutional characterization, transportation vs. healthcare framework orientation, federal funding mechanisms referenced, and notable findings and anomalies unique to each state.
This extraction framework is designed to enable cross-state and longitudinal comparison. No statistical methods are applied; the evidentiary weight rests on the repetition of findings by independent expert teams operating under standardized criteria.
Access & Replication
NHTSA Technical Assessment reports are produced for the assessed state and transmitted to the state EMS director, the State Highway Safety Official, and the NHTSA Regional Administrator. Distribution beyond these parties is at the discretion of the state. Reports are not systematically archived in a single federal repository, and NHTSA does not make them publicly available.
All 29 reports in this archive were obtained through public sources — not from NHTSA directly. Researchers seeking to locate additional reports may find them through:
Archive Limitations
NHTSA does not maintain a central public repository for Technical Assessment reports, and the agency does not make them publicly available. All reports in this archive were located through public records searches, state websites, internet archives, libraries, and state public records requests. As a result, this archive represents reports that could be publicly located — not the complete universe of assessments conducted. Known limitations include:
- New Hampshire (2018): Executive summary only; full TAT report not obtained. TAT composition not listed.
- 20 states from the 1995 baseline do not appear in this archive with subsequent reassessments: Alabama, Arizona, Arkansas, Delaware, Illinois, Indiana, Louisiana, Minnesota, New Jersey, New Mexico, New York, North Carolina, North Dakota, Pennsylvania, Texas, Utah, Virginia, West Virginia, and Wyoming. Some of these states may have been reassessed but reports were not accessible.
- Additional assessments beyond the 28 in this archive may have been conducted for states not represented here. The total number of assessments performed by NHTSA over the life of the program is not publicly documented.
- Pre-1991 original assessments referenced in reassessment reports (e.g., Colorado 1988, various 1989–1990 assessments) are documented in the 1995 evaluation but not individually archived here.
These Reports in Context
Every NHTSA assessment also appears in the Document Library and Interactive Timeline, alongside the federal legislation, policy papers, and historical events that shaped the EMS systems these reports evaluate.
Document Library Explore the Timeline